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Reporting Protocol for the Examination of Gross Autopsy of Adult DecedentsVersion: autopsy-adult-20.02Protocol Posting Date: February 2020

Accreditation RequirementsThe use of this protocol is recommended for autopsy but is not required for accreditation purposes.

This protocol may be used for the following procedures:Procedure DescriptionAutopsy Includes routine autopsy for adult decedents

The following should NOT be reported using this protocol:ProcedureForensic autopsyPediatric autopsy

AuthorsJody E. Hooper, MD*, Katie Flickinger, MS, PA (ASCP)CM*

With guidance from the CAP Autopsy and Neuropathology Committees.* Denotes primary author. All other contributing authors are listed alphabetically.

Summary of Changes20.02 – New autopsy reporting protocol

© 2020 College of American Pathologists (CAP). All rights reserved. For Terms of Use please visit www.cap.org/cancerprotocols.

http://www.cap.org/cancerprotocols

CAP Approved Autopsy-Adult-20.02

Reporting Template

Notes: This case summary may be useful for reporting autopsy findings but is not required for accreditation purposes. (NOTE A)

PATIENT IDENTIFICATION AND CONSENT FOR AUTOPSY

Patient name: ______________________

Consent and patient ID reviewed byDr. ____________________Mr./Ms. ____________________

Two unique patient identifiers reviewedPatient name: ____________________Date of birth: ____________________MRN: ____________________Other: ____________________

___ Type of autopsy___ Complete___ Brain only___ No head___ Chest only___ Abdomen only___ Other: ____________________

Name of consenter: ____________________

Relationship to the deceased: ____________________

PRIOR POSTMORTEM PROCEDURES

___ Organ Donation (select all that apply)___ Corneas___ Skin___ Bone and soft tissue (specify): _______________________ Organs (specify): _______________________ Other (specify): ____________________

___ Funerary Preparation (select all that apply)___ Eye caps___ Jaws wired or sewn closed___ Evidence of embalming (specify): _______________________ Other (specify): ____________________

+ Data elements preceded by this symbol may be of value but are not necessarily routinely reported. 2


EXTERNAL APPEARANCE

___ General ___ Well-developed___ Other (specify): ____________________

___ Age: _________

___ Race___ Caucasian___ African American___ Hispanic___ Asian___ Other (specify): ____________________

___ Sex___ Male___ Female___ Other (specify): ____________________

Body Weight (kilograms) _____kg

Body Length (centimeters) _____cm

BMI ______Note: use formula weight (kg)/ [height (m)]2

___ Personal effect with or on the body___ No___ Yes (specify): ____________________

___ Toes / fingernails:___ Unremarkable___ Onychomycosis___ Koilonychia___ Splinter hemorrhages___ Cyanotic___ Other (specify): ____________________

___ Skin___ Unremarkable___ Other (specify): ____________________

___ Palpable lymph nodes___ No___ Yes

___ Neck___ Axilla___ Groin ___ Other (specify): ____________________

___ Hair ___ None___ Balding___ Short___ Long



___ Other (specify): ____________________

___ Hair color___ Black___ Brown___ Blond___ Grey___ Other (specify): ____________________

___ Eye color___ Brown___ Blue___ Hazel___ Green___ Other (specify): ____________________

Pupil measurement- right (centimeters): _________ cm

Pupil measurement- left (centimeters): _________ cm

___ Sclerae___ Anicteric___ Icteric___ Other (specify): ____________________

___ Ears___ Unremarkable___ Other (specify): ____________________

___ Nose___ Unremarkable___ Other (specify): ____________________

___ Oral cavity___ Good dentition___ Poor dentition___ Dentures___ No teeth___ Exam not performed due to rigor___ Other (specify): ____________________

___ External genitalia___ Normal male___ Normal female___ Other (specify): ____________________

___ Leg circumference 10 cm from medial malleolus___ Right (centimeters): ________ cm___ Left (centimeters): ________ cm

___ Edema___ None___ Peripheral___ Generalized___ Other (specify): ____________________



___ Scars/ incisions___ None___ Present (specify): ____________________

___ Location (specify): ______________ Size (centimeters): ____ cm

___ Evidence of therapy___ None___ Nasogastric tube___ PEG tube___ Endotracheal tube___ Foley catheter___ Other (specify): ____________________

___ Back___ Unremarkable___ Other (specify): ____________________

INCISIONS AND BODY CAVITIES

___ Incision___ Standard Y-shaped___ Biparietal___ Other (specify): ____________________

___ Organs in normal anatomic positions___ Yes___ No___ Other (specify): ____________________

+ Panniculus (centimeters measured at thickest area): ________ cm

___ Peritoneal fluid___ None___ Present (milliliters): __________ ml

___ Serous___ Cloudy___ Serosanguinous___ Sanguinous___ Other (specify): ____________________

___ Peritoneal surfaces___ Smooth___ Adhesions___ Other (specify): ____________________

___ Right pleural cavity___ Smooth___ Adhesions___ Other (specify): ____________________



___ Right pleural fluid___ None___ Present (milliliters): __________ ml

___ Serous___ Serosanguinous___ Sanguinous___ Other (specify): ____________________

___ Left pleural cavity___ Smooth___ Adhesions___ Other (specify): ____________________

___ Left pleural fluid___ None___ Present (milliliters): __________ ml

___ Serous___ Serosanguinous___ Sanguinous___ Other (specify): ____________________

CARDIOVASCULAR SYSTEM

___ Heart weight___ (grams): _________ gNote: see reference table by patient weight

___ Pericardium___ Intact___ Adhesions___ No adhesions___ Other (specify): ____________________

___ Pericardial fluid___ None___ Present (milliliters): __________ ml

___ Serous___ Sanguinous___ Other (specify): ____________________

+ ___ Epicardial fat+ ___ Minimal+ ___ Moderate+ ___ Large amount+ ___ Other (specify): ____________________

___ Epicardial surface___ Smooth___ Glistening___ Roughened___ Other (specify): ____________________



___ Coronary ostia___ Normally positioned___ Patent___ Other (specify): ____________________

___ Foramen ovale___ Closed___ Probe patent___ Other (specify): ____________________

___ Coronary arteries follow normal anatomic course___ Yes___ No___ Other (specify): ____________________

___ Coronary circulation___ Right dominant___ Left dominant___ Co- dominant

Atherosclerosis___ Left anterior descending artery (LAD)

___ None___ % stenosis: _____________ Eccentric___ Concentric___ Other (specify): ____________________

___ Left circumflex artery (LCX)___ None___ % stenosis: _____________ Eccentric___ Concentric___ Other (specify): ____________________

___ Right coronary artery (RCA)___ None___ % stenosis: _____________ Eccentric___ Concentric___ Other (specify): ____________________

___ Chamber dilation___ Yes___ No___ Other (specify): ____________________

___ Valve leaflets___ Thin/ delicate___ Other (specify): ____________________

___ Chordae tendinae___ Thin___ Other (specify): ____________________



+ Valve circumferences+ Tricuspid (centimeters): _________ cm

____ Abnormalities (specify): ____________________ Note: Reference range 10.0 – 12.5 cm

+ Pulmonic (centimeters): _________ cm____ Abnormalities (specify): ____________________ Note: Reference range 7.0 – 9.0 cm

+ Mitral (centimeters): _________ cm____ Abnormalities (specify): ____________________ Note: Reference range 8.0 – 10.5 cm

+ Aortic (centimeters): _________ cm____ Abnormalities (specify): ____________________ Note: Reference range 6.0 – 7.5 cm

___ Myocardium___ Firm___ Red-brown___ Other (specify): ____________________

____ Endocardium___ Smooth and thin___ Thickened___ Other (specify): ____________________

Left ventricular free wall (centimeters): _________ cmNote: Reference range less than 1.5 cm

Right ventricular free wall (centimeters): _________ cmNote: Reference range less than 0.5 cm

Septum (centimeters): _________ cmNote: Reference range less than 1.5 cm

___ Pulmonary artery___ Appropriate caliber___ Normal configuration___ Contains embolus___ Other (specify): ____________________

___ Ascending aorta___ Appropriate caliber___ Normal configuration___ Other (specify): ____________________

___ Major arteries arising from aortic arch___ Normal configuration___ Patent___ Other (specify): ____________________



___ Thoracic aorta___ No atherosclerosis___ Mild atherosclerosis___ Moderate atherosclerosis___ Severe atherosclerosis

___ Abdominal aorta___ No atherosclerosis___ Mild atherosclerosis___ Moderate atherosclerosis___ Severe atherosclerosis

___ Venae cavae___ Patent___ Thin- walled___ Thrombi present___ Other (specify): ____________________

RESPIRATORY SYSTEM

___ Epiglottis, larynx, trachea___ No lesions___ Other (specify): ____________________

Right lung weight (grams): _________ gNote: Reference range 360 – 570 g

Left lung weight (grams): _________ gNote: Reference range 325 – 480 g

___ Fixation___ Fixed in distension___ Cut fresh___ Other (specify): ____________________

___ Right lung parenchyma___ Soft and pale red___ Other (specify): ____________________

___ Left lung parenchyma___ Soft and pale red___ Other (specify): ____________________

___ Bronchi___ Patent___ Other (specify): ____________________

___ Bronchial mucosa___ No lesions___ Other (specify): ____________________



___ Pulmonary arteries___ No atherosclerosis___ Atherosclerosis___ Pulmonary emboli (specify size and location)___ No pulmonary emboli___ Other (specify): ____________________

DIGESTIVE SYSTEM

+ ___ Tongue+ ___ Papillated+ ___ Smooth+ ___ Other (specify): ____________________

___ Esophagus___ Normal anatomic configuration___ Other (specify): ____________________

___ Esophageal mucosa___ White___ Intact___ Other (specify): ____________________

___ Squamocolumnar junction___ Sharply defined___ Indistinct___ Other (specify): ____________________

___ Stomach___ Empty___ Distended___ Contains partially digested food and liquids___ Other (specify): ____________________

___ Gastric mucosa___ Intact, rugated___ Other (specify): ____________________

___ Appendix___ Present___ Surgically absent___ Other (specify): ____________________

___ Small bowel___ Usual caliber___ Dilated___ Strictured___ Other (specify): ____________________

___ Small bowel serosa___ Tan pink shiny___ Adhesions___ Other (specify): ____________________



Small bowel contents (specify): ____________________

___ Small bowel mucosa___ Tan___ No lesions___ Other (specify): ____________________

___ Large bowel___ Usual caliber___ Dilated ___ Stricture___ Other (specify): ____________________

___ Large bowel serosa ___ Tan pink shiny___ Adhesions___ Other (specify): ____________________

Large bowel contents (specify): ____________________

___ Large bowel mucosa___ Tan ___ No lesions___ Polyps___ Diverticula___ Other (specify): ____________________

+ ___ Superior mesenteric artery+ ___ No atherosclerosis+ ___ Degree of atherosclerosis (specify): ____________________+ ___ Other (specify): ____________________

Liver weight (grams): __________ gNote: Reference range 1500 – 1800 g

___ Liver capsule___ Smooth___ Glistening___ Intact___ Other (specify): ____________________

___ Liver parenchyma___ Slightly firm___ Firm___ Soft___ Maroon-brown___ Green tinged___ Yellow orange___ Rusty brown___ Mottled red___ Nodular___ No focal lesions___ Other (specify): ____________________



___ Gallbladder___ Present___ Surgically absent___ Other (specify): ____________________

___ Gallbladder wall___ Thin___ Fibrous___ Other (specify): ____________________

___ Gallbladder mucosa___ Velvety___ Green___ Other (specify): ____________________

___ Gallbladder contents___ Dark green mucoid bile___ No calculi___ Calculi___ Other (specify): ____________________

___ Extrahepatic biliary system___ Patent___ Other (specify): ____________________

___ Portal vein___ Patent___ Other (specify): ____________________

___ Hepatic arteries___ Patent___ Other (specify): ____________________

___ Hepatic veins___ Patent___ Other (specify): ____________________

Pancreas dimensions (centimeters): ____ cm x ____ cm x ____ cmNote: Average 23.0 x 4.5 x 3.8 cm

___ Pancreatic parenchyma___ Tan___ Firm and lobulated___ Autolyzed___ Other (specify): ____________________

___ Pancreatic duct___ Patent___ Not probe patent___ Other (specify): ____________________



URINARY TRACTNote: Average combined kidney weight 230-440 g

Right kidney weight (grams): __________ g

___ Right kidney cortex___ Thickness (centimeters): ____ cm___ Smooth___ Granular___ Scarred___ Other (specify): ____________________

___ Right kidney parenchyma___ Red-brown___ Clearly demarcated corticomedullary junctions___ Ill-defined corticomedullary junctions___ Other (specify): ____________________

___ Right ureter___ Patent___ Not patent___ Dilated___ Not dilated___ Other (specify): ____________________

Left kidney weight (grams): __________ g

___ Left kidney cortex___ Thickness (centimeters): ____ cm___ Smooth___ Granular___ Scarred___ Other (specify): ____________________

___ Left kidney parenchyma___ Red-brown___ Clearly demarcated corticomedullary junctions___ Ill-defined corticomedullary junctions___ Other (specify): ____________________

___ Left ureter___ Patent___ Not patent___ Dilated___ Not dilated___ Other (specify): ____________________

___ Renal arteries___ Patent___ No atherosclerosis___ Mild atherosclerosis___ Moderate atherosclerosis___ Severe atherosclerosis



___ Bladder___ Collapsed___ Volume of urine (milliliters): __________ ml

___ Bladder mucosa___ Intact___ Other (specify): ____________________

MALE REPRODUCTIVE TRACT (if appropriate)

___ Prostate___ Normal size___ Enlarged___ Nodular___ Size (centimeters): ____ cm x ____ cm x ____ cm___ Other (specify): ____________________

___ Testes___ Normal size___ Enlarged___ Other (specify): ____________________

___ Testes cut surface___ Brown parenchyma___ Tubules string in normal manner___ Tubules do not string___ Other (specify): ____________________

FEMALE REPRODUCTIVE TRACT (if appropriate)

___ Uterus___ Present and appropriate size___ Present (comment): _______________________ Surgically absent

___ Right Ovary ___ Size (centimeters): ____ cm x ____ cm x ____ cm___ Not identified___ Other (specify): ____________________

___ Left Ovary ___ Size (centimeters): ____ cm x ____ cm x ____ cm___ Not identified___ Other (specify): ____________________

___ Endometrium ___ Pale___ Red___ Other (specify): ____________________

___ Vagina___ Without lesions___ Other (specify): ____________________



___ Cervix___ Without lesions___ Other (specify): ____________________

ENDOCRINE SYSTEM

Right adrenal weight (grams): __________ gNote: Average weight 6 g (trimmed)

Left adrenal weight (grams): __________ gNote: Average weight 6 g (trimmed)

___ Adrenal parenchyma___ Uniform yellow cortices___ Good demarcation from the medullae___ Autolyzed___ Other (specify): ____________________

___ Thyroid___ Weight (grams): __________ g___ Symmetrical___ Red-brown___ Firm___ Nodular___ Other (specify): ____________________Note: Average weight 30 – 70 g

___ Breast tissue contains small amount of white fibrous tissue within yellow fat___ Other (specify): ____________________

LYMPHORETICULAR SYSTEM

Spleen weight (grams): __________ gNote: Average weight 150 – 200 g unless over 80-years-old, then average 100 g

___ Spleen capsule___ Smooth___ Intact___ Other (specify): ____________________

___ Spleen parenchyma___ Dark red___ Other (specify): ____________________

___ Bone marrow___ Dark red___ Hard___ Softer than usual___ Other (specify): ____________________

___ Lymph nodes___ Not enlarged___ Other (specify): ____________________



___ Thymus___ Not identified___ Age appropriate fatty replacement___ Present (weigh)___ Other

MUSCULOSKELETAL SYSTEM

___ Diaphragm___ Intact___ Other (specify): ____________________

___ Skeletal muscles___ Red-brown and firm___ Appropriate mass for age/ gender___ Other (specify): ____________________

___Calvarium___ Intact___ Normal thickness___ Other (specify): ____________________

___ Vertebral column___ Normal curvature___ Kyphosis___ Scoliosis___ Other (specify): ____________________

___ Ribs___ Fractures (specify): _______________________ No fractures___ Other (specify): ____________________

___ Vertebral bodies___ No fractures___ Other (specify): ____________________

CENTRAL NERVOUS SYSTEMGross brain observations at time of autopsy. Post-fixation brain cutting observations and tissue sampling will be considered in separate protocol (under development)

Brain weight (grams): __________ gNote: Average weight 1100 – 1600 g

___ Dura___ No lesions___ Epidural hemorrhage___ Subdural hemorrhage___ Removal reveals no bony abnormalities___ Other (specify): ____________________

___ Leptomeninges___ No lesions___ Subarachnoid hemorrhage



___ Opacity or discoloration___ Other (specify): ____________________

___ Cerebral hemispheres___ No lesions___ Asymmetric (specify):_____________________ Atrophy (specify: diffuse, focal, lobar): ______________________ Edema (specify: diffuse, focal): _____________________ Other (specify): ____________________

___ Base of brain___ No lesions___ Uncal herniation

___ Circle of Willis___ Normal___ Atherosclerosis (specify location and severity): ____________________ Aneurysm (specify location and type): _______________* Note: If a ruptured aneurysm is suspected clinically and hemorrhage is present at the base of

the brain, it is advisable to wash away the blood and conduct a thorough search for the aneurysm before fixation of the brain.

___ Other (specify): ______________

___ Cerebellum___ No lesions___ Tonsillar herniation___ Other (specify): ____________________

___ Brainstem___ No lesions___ Other (specify): ____________________

___ Spinal cord___ Length (cm from cut superior to conus): ___________cm___ No lesions___ Other (specify): _______________________ Not submitted

___ Pituitary___ No lesions___ Other (specify): ____________________

+ EYES

+ ___ Eyes+ ___ Submitted+ ___ Not submitted+ ___ Other (specify): ____________________

AUTOPSY PROCEDURES AND ANCILLARY TESTING

___ Approach to autopsy dissection___ Rokitansky



___ Virchow___ Other (specify): ____________________

___ Special dissection___ None___ Other (specify): ____________________

___ Tissue retention___ Stock jar___ All organs (until signout)___ Other (specify): ____________________

___ Additional samples taken___ Blood (specify): _______________________ Vitreous___ Tissue (specify): _______________________ Other (specify): ____________________

___ Ancillary testing___ None___ Radiology (specify): _______________________ Blood cultures (specify): _______________________ Tissue cultures (specify): _______________________ Toxicology (specify): _______________________ Other (specify): ____________________


Background Documentation Autopsy-Adult-20.02

Explanatory Notes

A. IntroductionThe aim of this protocol is to improve the completeness, clarity, and portability of autopsy reporting, while being mindful of the wide range of practice settings in which the data in the report is generated and disseminated. Autopsy reporting has traditionally been entirely in prose, a methodology which complicates real time dictation in many cases, and which does not make data easily retrievable, particularly across institutions.

The protocol is based upon input from past and present members of the CAP Autopsy Committee, CAP Neuropathology Committee, and input from Katie Flickinger, MS, PA(ASCP)CM as well as the references below.

The construction of this protocol does allow for the insertion of sentences where desired and thus combines the best of templating and traditional description. It is recommended that it be used as a paper copy or electronic tool directly in the autopsy suite while a case is being completed, though its use can be adapted as needed at different centers and depending on the information technology environment. Portions of the template may also be used in limited autopsies. Though this template represents the Autopsy Committee’s recommendations for inclusion in an autopsy report, some sections with a plus sign “+” are considered more readily optional in practice and could be omitted.

Not only will the template provide more easily reproducible and extractable data, it may be used as a guide for trainees and pathologists who may only perform a limited number of autopsies in their practice. The committee hopes this is a first step in providing a general framework for more standardized quality autopsy practice.

The content of the protocol represents the consensus opinion of the CAP Autopsy Committee. It was ordered by organ system rather than order of the block dissection in recognition of variations in dissection practices across institutions as well as to create the most intelligible final report. Recognizing that the order of elements may be adjusted by users, it is the Committee’s recommendation that all elements be included in the Gross Description. Microscopic sampling can also be institution dependent, but the Committee recommends broad histologic evaluation for autopsies.

References1. Fyfe-Kirschner B and Miller DK. The future of autopsy reporting: data repository and research support. In:

Hooper and Williamson, editors. Autopsy in the 21st Century: Best Practices and Future Ideas. Switzerland: Springer;2019. 39-56.

2. Wittekind C, Habeck JO, Gradistanac T. Proposals for standardization of autopsy reports. Pathologe 2014;35:182-190. https://doi.org/10.1007/s00292-013-1885-8.

3. Hanzlick R. The autopsy lexicon: suggested headings for autopsy reports. In: Collins K, editor. Autopsy Performance and Reporting. 3rd ed. Chicago: CAP Press;2017. 377-382.

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