Renal Parenchymal Malignancy Histopathology Reporting

Structured Reporting of Renal Parenchymal Malignancy using a standard protocol re-constructed in a FileMaker database. The database Kidney Protocol records answer data for 101 core questions in 6 groups. Data is recorded for patient identification, observations about the clinical specimen, macroscopic and microscopic findings of the renal specimen, ancilary test findings, and tumour stage and grouping. The completed data is reported as print or PDF output.

Patient Identification data

Family Name, Given Name, Gender, Date Of Birth, Patient Identifiers, Date of Request, Path Accession No., Requesting doctor name, Requesting doctor phone, Requesting doctor contacted.

Clinical details data

Identification and contact details of requesting doctor, Relevant clinical information (per request form), Principal clinician, Relevant past medical history, Details of any predisposing factors (including genetic status), Details of any adjuvant therapy, Details of any relevant family history, Details regarding extent of disease, Details of previous biopsy/surgical specimens, Laterality, Clinical or differential diagnosis, Nature of operation, Operative findings, Surgical intent, Tissue removed for research or other purposes, Details of tissue removed.

Macroscopic findings data

Nature of specimen, Fixative, Length, Width, Thickness, Weight, Evidence of infiltration to adrenal gland, Length of ureter, Length of renal vein, Length of renal artery, Evidence of tumour within lumen vein, Length, Width, Thickness, Adherence of renal capsule to the visceral surface of perirenal fat, Abnormalities on cortical surface, Position of tumour, Multiple tumours?, Number of tumours, Description of tumour, Length, Width, Thickness, Distance between tumour and renal capsule, Evidence of infiltration to, Appearance of cut surface, Details, Necrosis , Colour of tumour, Consistency, Details.

Microscopic findings data

Tumour type, type, Other(specify), Tumour grade, Sarcomatoid differentiation, Percentage of tumour, Rhabdoid differentiation, Percentage of tumour, Necrosis, Tumour spread beyond kidney, Tumour extends beyond Gerota's fascia, Tumour in renal sinus fat, Tumour within small intra-renal vessels (microvascular invasion), Tumour in renal sinus lymphatics, Tumour in muscle containing vessels within renal sinus, Tumour in renal vein, Tumour in pelvi-calyceal system, Tumour in adrenal gland, As a result of, Site, Number of nodes involved by tumour, Total number of nodes resected, Tumour in other organs, Specify organs, As a result of, Involvement of surgical margins, Specify margin, For partial nephrectomy specimens, distance of tumour from closest surgical margin., Co-existing renal pathology, Additional microscopic comment.

Ancillary Test findings data

Test Type Name, Performing Lab, Method, Conclusion, Result, Person responsible for reporting.

Synthesis and Overview data

T, N, M, Stage Grouping, Year of publication and edition of cancer staging system, Diagnostic summary, Other relevant information and comments, Overarching comment.