CAP Soft.Tissue\_4.1.0.0.REL\_CAPCP Approved

### Accreditation Requirements

This protocol can be utilized for a variety of procedures and tumor types for clinical care purposes. For accreditation purposes, only the definitive primary cancer resection specimen is required to have the core and conditional data elements reported in a synoptic format.

- • data elements are required in reports to adequately describe appropriate malignancies. For • data elements are required in reports to adequately describe appropriate malignancies. For accreditation purposes, essential data elements must be reported in all instances, even if the response is “not applicable” or “cannot be determined.”
- • data elements are only required to be reported if applicable as delineated in the • data elements are only required to be reported if applicable as delineated in the protocol. For instance, the total number of lymph nodes examined must be reported, but only if nodes are present in the specimen.
- • data elements are identified with “+” and although not required for CAP accreditation • data elements are identified with “+” and although not required for CAP accreditation purposes, may be considered for reporting as determined by local practice standards.

The use of this protocol is not required for recurrent tumors or for metastatic tumors that are resected at a different time than the primary tumor. Use of this protocol is also not required for pathology reviews performed at a second institution (ie, secondary consultation, second opinion, or review of outside case at second institution).

### Synoptic Reporting

All core and conditionally required data elements outlined on the surgical case summary from this cancer protocol must be displayed in synoptic report format. Synoptic format is defined as:

- • element: followed by its answer (response), outline format without the paired Data element: • element: followed by its answer (response), outline format without the paired Data element: Response format is NOT considered synoptic.
- • data element should be represented in the report as it is listed in the case summary. The • data element should be represented in the report as it is listed in the case summary. The response for any data element may be modified from those listed in the case summary, including “Cannot be determined” if appropriate.
- • diagnostic parameter pair (Data element: Response) is listed on a separate line or in a tabular • diagnostic parameter pair (Data element: Response) is listed on a separate line or in a tabular format to achieve visual separation. The following exceptions are allowed to be listed on one line:
- o site or specimen, laterality, and procedure o site or specimen, laterality, and procedure
- o Stage Classification (pTNM) elements o Stage Classification (pTNM) elements
- o margins, as long as all negative margins are specifically enumerated where o margins, as long as all negative margins are specifically enumerated where applicable
- • synoptic portion of the report can appear in the diagnosis section of the pathology report, at • synoptic portion of the report can appear in the diagnosis section of the pathology report, at the end of the report or in a separate section, but all Data element: Responses must be listed together in one location

Organizations and pathologists may choose to list the required elements in any order, use additional methods in order to enhance or achieve visual separation, or add optional items within the synoptic report. The report may have required elements in a summary format elsewhere in the report IN ADDITION TO but not as replacement for the synoptic report ie, all required elements must be in the synoptic portion of the report in the format defined above.

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