Cancer Synoptic Report (Uterine Corpus Resection)

Cancer Synoptic Report — Uterine Corpus (Endometrium) Resection

(All synoptic elements formatted as Data element: Response. Use standardized terminology. If an element cannot be assessed, state "cannot be assessed" with brief reason. For items not applicable, state "not applicable." Distinguish between "not identified" (examined, negative) and "not submitted.")

Report date: [Report date]

Case/accession identifier: [Accession/case ID]

Staging system: AJCC 8th edition pTNM; provisional FIGO 2023 stage

Clinical Information

(Include only if clinical context provided or explicitly documented as not provided.)

Clinical history: [Brief clinical context / Not provided]

Prior therapy status: [No neoadjuvant therapy / Post-neoadjuvant therapy (y prefix) / Post-hormonal therapy (y prefix)]

Known hereditary syndrome: [None reported / Lynch syndrome / Other: specify / Not provided]

Specimen / Procedure

(List only tissues actually received. Document if specimen integrity compromises assessment.)

Procedure performed: [Total hysterectomy / Total hysterectomy with BSO / Radical hysterectomy / Supracervical hysterectomy / Other: specify]

Specimen integrity: [Intact / Disrupted / Morcellated]

Integrity impact on assessment: [No significant limitation / Assessment of size/invasion/margins/nodal counts compromised due to fragmentation]

Specimens submitted: [Uterus; cervix; right adnexa; left adnexa; omentum; peritoneal biopsies; pelvic lymph nodes; para-aortic lymph nodes; peritoneal washings; other: specify] (List only submitted specimens)

Tumor (Primary)

(Do not infer invasion or size from gross appearance alone. Use measured and histologically confirmed findings.)

Tumor present: [Present / No residual carcinoma identified]

Tumor focality: [Unifocal / Multifocal / Cannot be assessed]

Tumor size, greatest dimension: [X.X cm / At least X.X cm (fragmented) / Cannot be assessed]

Lower uterine segment involvement: [Present / Not identified / Cannot be assessed]

Histologic type: [Endometrioid carcinoma / Serous carcinoma / Clear cell carcinoma / Carcinosarcoma / Mixed carcinoma / Undifferentiated carcinoma / Dedifferentiated carcinoma / Other: specify]

Mixed carcinoma components: [Component 1 (X%), component 2 (X%) / Not applicable]

Histologic grade: [FIGO grade 1 / FIGO grade 2 / FIGO grade 3 / High-grade (non-endometrioid) / Cannot be assessed: reason]

Myometrial invasion: [Present / Not identified / Cannot be assessed]

Depth of myometrial invasion: [<50% of myometrial thickness / ≥50% of myometrial thickness / Cannot be assessed]

Percent myometrial thickness invaded: [X% / Cannot be assessed]

Depth of invasion: [X.X mm / Not measured]

Total myometrial thickness: [X.X mm / Not measured]

Myometrial invasion comment: [Irregular endomyometrial junction / Exophytic tumor / Cornual involvement / Arising in adenomyosis / Other: specify / Not applicable] (Include only if interpretation affected)

Cervix present and assessable: [Yes / No (supracervical hysterectomy) / Cannot be assessed]

Cervical stromal invasion: [Present / Not identified / Not applicable]

Depth of cervical stromal invasion: [X.X mm / X% / Not measured / Not applicable]

Endocervical glandular involvement only: [Present / Not identified / Not applicable]

Lymphovascular space invasion (LVSI): [Not identified / Present / Indeterminate]

LVSI extent: [Focal / Substantial / Not applicable]

LVSI comment: [Clarification / Not applicable] (Use for pseudo-LVSI concern or immunostain confirmation)

Uterine serosal involvement: [Present / Not identified / Cannot be assessed]

(For extrauterine sites, include only those actually submitted. Use: Not submitted / Submitted, not involved / Involved)

Right ovary: [Not submitted / Submitted, not involved / Involved]

Left ovary: [Not submitted / Submitted, not involved / Involved]

Right fallopian tube: [Not submitted / Submitted, not involved / Involved]

Left fallopian tube: [Not submitted / Submitted, not involved / Involved]

Vagina: [Not submitted / Submitted, not involved / Involved]

Parametria: [Not submitted / Submitted, not involved / Involved]

Pelvic peritoneum: [Not submitted / Submitted, not involved / Involved]

Omentum: [Not submitted / Submitted, not involved / Involved]

Other site(s): [Specify site and involvement status / Not applicable]

Peritoneal washings/cytology: [Negative for malignant cells / Malignant cells present / Atypical/suspicious / Pending / Not submitted]

Margins

(Include only when true surgical margins present: ectocervical/vaginal cuff, parametrial soft tissue, or lower uterine segment margin in supracervical procedures.)

Margin status: [Negative / Positive / Cannot be determined: reason / Not applicable]

Closest negative margin: [Margin site, X.X mm / Not applicable]

Positive margin(s): [Specify involved margin(s); focal/multifocal/extensive / Not applicable]

Margin comment: [Explanation of limitation / Not applicable]

Regional Lymph Nodes

(Organize by anatomic group and sentinel vs non-sentinel if tracked. Use "at least X" if fragmentation limits counts.)

Regional lymph nodes submitted: [Yes / No]

Sentinel lymph node protocol performed: [Yes / No]

Pelvic sentinel nodes: [X examined, X positive / Not applicable]

Pelvic sentinel node metastasis categories: [Macrometastasis: X; Micrometastasis: X; ITC: X / Not applicable]

Pelvic sentinel node largest deposit: [X.X mm / Not applicable]

Pelvic sentinel node detection method: [Routine H&E / Ultrastaging / Not applicable]

Pelvic non-sentinel nodes: [X examined, X positive / Not applicable]

Pelvic non-sentinel node metastasis categories: [Macrometastasis: X; Micrometastasis: X; ITC: X / Not applicable]

Para-aortic sentinel nodes: [X examined, X positive / Not applicable]

Para-aortic sentinel node metastasis categories: [Macrometastasis: X; Micrometastasis: X; ITC: X / Not applicable]

Para-aortic sentinel node largest deposit: [X.X mm / Not applicable]

Para-aortic sentinel node detection method: [Routine H&E / Ultrastaging / Not applicable]

Para-aortic non-sentinel nodes: [X examined, X positive / Not applicable]

Para-aortic non-sentinel node metastasis categories: [Macrometastasis: X; Micrometastasis: X; ITC: X / Not applicable]

Nodal assessment comment: [Explanation / Not applicable]

Distant Metastasis (Pathologically Confirmed)

(Include only if tissue from non-regional sites submitted and examined.)

Distant site(s) submitted: [List sites / Not applicable]

Pathologically confirmed distant metastasis: [Present: specify site(s) / Not identified / Not applicable]

Pathologic Stage

(Assign AJCC 8th pTNM with applicable modifiers. FIGO 2023 stage is provisional; may require update pending molecular results.)

AJCC staging modifier: [None / y (post-treatment) / r (recurrent)]

AJCC pT: [pT1a / pT1b / pT2 / pT3a / pT3b / pT4 / pTX: reason]

AJCC pN: [pN0 / pN0(i+) / pN1mi / pN1 / pN2mi / pN2 / pNX: reason]

AJCC pM: [pM1 / Not applicable (no distant site evaluated)]

FIGO stage (2023, provisional): [IA / IB / II / IIIA / IIIB / IIIC1 / IIIC2 / IVA / IVB / Cannot be assigned: reason]

Staging comment: [Stage may be updated when molecular results finalize / Other clarification / Not applicable]

Ancillary Studies

(Include when performed or pending. Use explicit "pending" rather than omitting clinically impactful elements.)

MMR immunohistochemistry: [MLH1: retained/lost; PMS2: retained/lost; MSH2: retained/lost; MSH6: retained/lost]

MMR interpretation: [Proficient (pMMR) / Deficient (dMMR) / Indeterminate / Pending]

p53 immunohistochemistry: [Wild-type / Aberrant (overexpression) / Aberrant (complete absence) / Indeterminate / Pending]

POLE sequencing: [Pathogenic variant: specify / No pathogenic variant / VUS only / Not performed / Pending]

Molecular classifier: [POLEmut / MMRd / p53abn / NSMP; Final/Pending / Not performed]

Additional Findings

Endometrial intraepithelial neoplasia/atypical hyperplasia: [Present / Not identified]

Other significant findings: [Specify / None]

Comment

(Use sparingly for staging-relevant clarifications or interpretive considerations not captured in structured elements.)

Comment: [Explanatory note / None]