or associated naevus with the melanoma naevus En:Primary Lesion The primary lesion and typically the reason why the report is being prepared. The lesion will usually be described in various ways and this should be recorded. dermal component, lesion, nodule ) Other lesions mentioned in the report and described second lesion Reference to any satellites associated with the melanoma satellite, microsatellites Used to identify the specimen. Differentiate from the specimen heading tag. specimen, sections, 1., I. Type refers to the type of specimen that was used SNB (sentinel node biopsy), biopsy, shave, punch, ellipse of skin Description of the primary cell type in the entity. epithelioid, spindled, naevoid,pleomorphic, The cell growth pattern contributes to the identification of the sub-type of melanoma pagetoid, lentiginous spread , vertical growth phase Changes in appearance to the surrounding area that may be noted in the report and may be relevant to the diagnosis or the prognosis. scar, necrosis, changes description of the entity including colour, border and contour descriptions pigmented, purplish, circular, linear, scalloped The body part and side on which the lesion is located. This may also include finer locating information such as upper, lower, mid. (R) neck, left thigh, lower back, mid back Size refers to 2mm, 10x3mm, 6mm
the size of the sample sent for testing, the primary lesion and any other lesions or entities. Any reference to ulceration of a lesion or discontinuity of the skin resulting in loss of function ulcerated, ulceration Level of dermal mitosis and / or the mitotic rate. mitoses, mitotic rate is 15 to 18 per mm2 Statement that the excision margins are clear or any descriptive material relating to the excision margins that doesn’t belong under the other tags. This is particularly relevant to the excision biopsies because it relates to whether they have removed the entire tumour. excision appears complete, lines of excision are clear The distance from the lesion to the deep margin deep margin of 2.3mm, Distance from deep margin = 4.0mm The distance from the in-situ or junctional component to the lateral margins closest peripheral margin to in situ component measures 0.9mm, in situ component is situated 0.2mm The distance from the dermal component to the lateral margins (default category for lateral margins) closest peripheral margin to invasive component = 1.0mm, 5.95mm to the nearest lateral margin Reference to the presence or absence of desmoplasia. desmoplastic, desmoplasia Any reference to tumour infiltrating lymphocytes (TILs). inflammatory infiltrate, tumour nfiltrating lymphocytes Evidence of skin reaction to sun. It will make the skin appear leathery and can impact solar elastosis, skin
on diagnosis and prognosis. Evidence of reaction in connective tissue or scarring fibrosis, angiofibroplasia Any reference to infiltration of the blood vessels and lymphatic system. vascular invasion, vascular/lymphatic invasion Reference to any neurotropism present or absent. perineural invasion, neurotropism Primary tumour thickness Breslow thickness 1.6mm, depth 0.55mm In: Clark level The of the skin into which the tumour has permeated level 4, Clark level II Negative Lexically bound (either in a separate lexical item or as a suffix or prefix) polarity that is modifying something else. It will be related by negation. no, not, lack, nor Positive Lexically bound (either in a separate lexical item or as a suffix or prefix) polarity that is modifying something else. It will be related by confirmation. evidence, noted, present Modality in the positive direction possibly, probably, may, definite Adjuncts Indication of degree or intensity mild, moderate, some, small Any reference to temporal indicators previous, precursor, late This refers to the diagnosis of the lesion within the specimen. malignant melanoma, melanoma, basal cell carcinoma Any reference to regression within the lesion regression, regressive activity Refers to the histological type and classification of the melanoma only and will typically map superficial spreading type, nodular, lentigo maligna
values (the occurrences of the tokens inside it in candidates), if the tokens inside it occur in other candidates; else 0. “Sy:Diagnosis” Primary 1, if it refers to the primary lesion: else 0. “Ma:Excision In Situ”, “Ma:Excision Invasive”, “Ma:Excision Deep” Modality 1, if concept(s) of “Li:Modality” and the candidate occur in the same sentence; else 0. “De:Ulceration”, “En:Associated naevus (type)”, “In:Vascular/Lymphatic”, “In:Neurotropism”, “En:Satellites”, “Re:Desmoplasia”, “Sy:Diagnosis”, “Sy:Subtype” Temporality 1, if concept(s) of “Li: Temporality” and the candidate occur in the same sentence; else 0. “Sy:Diagnosis”, “De:Cosmetic Changes”, “Sy:Regression” Special Body_structure 1, if its medical category is “Body structure”; else 0. “De:Site and Laterality” Laterality 1, if it contains word(s) indicating laterality (e.g., “left”, ‘right”); else 0. “De:Site and Laterality” Melanoma 1, if it contains “melanoma”, “malignant”, “malignancy”, or “tumour”; else 0. “Sy:Diagnosis” Naevus 1, if it contains “naevus”; else 0. “En:Associated naevus (type)” Level 1, if it states the level explicitly (e.g., “Clark level III”), instead of the description (e.g., “extending into and filling the papillary dermis”); else 0. “In:Clark Level” Regress 1, if it contains word(s) 'Sy:Regression'
indicating stage or characteristic; else 0. Dimension 1, if it contains “x” ; else 0. “De:Size” Position 1, if it is in the first place; else 0 “De:Size” Specimen_ type 1, if concept(s) of “De:Specimen type” and the candidate occur in the same sentence; else 0. “De:Size” Positive 1, if its polarity is “positive”; else 0. “Ma:Excision Margin 1, if concept(s) of “Ma:Excision In Situ”, “Ma:Excision Invasive”, “Ma:Excision Deep” and the candidate occur in the same sentence; else 0. “Ma:Excision Clear” Distrubution_density 2, if it or 'Li:Mood and Comment Adjuncts' instances around it contains word(s) indicating distribution and density; 1, if only distribution or density; else 0. “Re:TILs” Appendix 4. Possible values for each item in the structured template. Section Item Value Diagnostic Summary Summary The contents in “DIAGNOSIS” section, N/A Comment The contents in “COMMENT” section, N/A Supporting Information CLINICAL Description The contents in “CLINICAL HISTORY” and / or “SPECIMEN” sections, N/A Site and laterality a particular site, N/A Clinical diagnosis a particular diagnosis (polarity or modality may be included) , N/A Specimen type a particular specimen type, N/A
Supporting Information CLINICAL Description The contents in the “CLINICAL HISTORY” and / or “SPECIMEN” sections Site and laterality BCI of “De:Site and Laterality” Expand abbreviations to full expressions: “L”, “(L)”, “Lt” “left”; “R”, “(R)”, “Rt” “right”. Examples: (1) “L Arm” “left arm”; (2) “(R) face” “right face”. Clinical diagnosis BCI of “Sy:Diagnosis”, “Sy:Subtype”, “En:Associated naevus (type)” in “CLINICAL HISTORY” and / or “SPECIMEN” sections General_Rule_2. Examples: (1) “?[“Li:Modality”] lentigo maligna[“Sy:Subtype”]” “possibly lentigo maligna”; (2) “exclude[“Li:Lexical Polarity Negative”] malignant melanoma[“Sy:Diagnosis”]” “no malignant melanoma”. Specimen type BCI of “De:Specimen Type” Prev. Rx / Trauma BCI of “De:Cosmetic Changes” (indicating “trauma”/ “Rx”) Only if instance(s) of “Li:Temporality” is in the same sentence, the is BCI (temporality). Example: (1) “previous [“Li:Temporality”] surgical procedure” [“De:Cosmetic Changes”] “surgical procedure(previous)”. Previous melanoma BCI of “Sy:Diagnosis” (indicating “melanoma”) Only if instance(s) of “Li:Temporality” is in the same sentence, then General_Rule_2. Example: (1) “Past history[“Li:Temporality”] of malignant melanoma[“Sy:Diagnosis”]” “present”. Distant metastasis BCI of “Sy:Diagnosis” (indicating “metastasis”) General_Rule_4. Other medical history BCI of “En:Primary Lesion”, “En:Associated naevus (type)”, “De:Cosmetic Changes” in “CLINICAL HISTORY” and / or “SPECIMEN” sections
MACROSCOPIC Description The contents in “MACROSCOPIC” section Size of specimen BCI of 'De:Size' It is handled by a module called “SizeProcesser”. If “diameter” is indicated, it will be preserved. Generally, one-dimension size is presented as itself; two-dimension size is presented as “Dimension1 x Dimension2”; three-dimension size is presented as “Dimension1 x Dimension2 x Dimension3” ; four-dimension size is presented as “Dimension1 x Dimension2 x Dimension3 x Dimension4”. Examples: (1) “4mm in diameter and 2mm in depth” “4mm diameter and 2mm depth(4mm dia x 2mm)”; (2) “9.5mm dia” “9.5mm diameter”; (3) “7x6mm” “7mm x 6mm”; (4) “13x8x2mm” “13 mm x 8mm x 2mm”; (5) “5 x 6 mm to a depth of 3 mm” “5mm x 6mm x 3mm”; (6) “5mm and 7mm in maximal dimension” “5mm x 7mm”; (7) “65mm in length, width of 30mm and maximum thickness of 13mm” “65mm x 30mm x 13mm”; (8) “15mm in maximal dimension” “15mm”; (9) “17 x 12 mm across with a depth of up to 7 mm” “17mm x 12mm x 7mm”; (10) “10x10x8mm and 4mm in depth” “10mm x 10mm x 8mm x 4mm”. lesions BCI of “En:Lesion (other)” General_Rule_4. MICROSCOPIC Description The contents in “MICROSCOPIC” section Diagnosis BCI of “Sy:Diagnosis” in “MICROSCOPIC” section General_Rule_2. Examples: (1) “no[“Li:Lexical Polarity Negative”] evidence of malignancy[“Sy:Diagnosis”]” “no malignancy”; (2) cell carcinoma” “basal cell carcinoma”. Tumour thickness BCI of “In:Breslow Thickness (mm)” General_Rule_3. Examples: (1) “thickness of 5.0mm” “5.0mm”;