Surgical Pathology Cancer Case Summary

ANUS:             Report

 

Surgical Pathology Cancer Case Summary

 

ANUS: Biopsy/Polypectomy

MACROSCOPIC (check all that apply)

 

SPECIMEN TYPE

___ Biopsy

___ Polypectomy

 

TUMOR SITE

___ Unknown

___ Anterior wall

        (Distance from anal verge: ___ cm)

        ___ Distance from anal verge unknown

___ Posterior wall

        (Distance from anal verge: ___ cm)

        ___ Distance from anal verge unknown

___ Right wall

        (Distance from anal verge: ___ cm)

        ___ Distance from anal verge unknown

___ Left wall

        (Distance from anal verge: ___ cm)

        ___ Distance from anal verge unknown

___ Anal margin

 

POLYPECTOMY ONLY

Polyp size: ___ x ___ x ___

 

Polyp configuration:

___ Pedunculated

       ___ Stalk (stalk length: ___ cm)

       ___ No stalk

___ Sessile

 

 

MICROSCOPIC (check all that apply)

 

HISTOLOGIC TYPE

___ Squamous cell carcinoma

        ___ Large cell keratinizing

        ___ Large cell nonkeratinizing

        ___ Basaloid

        ___ Carcinoma in situ (Bowen’s disease)

___ Adenocarcinoma

        ___ Rectal type

        ___ Of anal glands

        ___ Within anorectal fistula

        ___ Paget’s disease

___ Small cell carcinoma

___ Giant condyloma (verrucous carcinoma)

___ Basal cell carcinoma

___ Undifferentiated carcinoma

___ Other:___________________

 

HISTOLOGIC GRADE (if applicable to tumor type)

___ Not applicable

___ GX:    Cannot be assessed

___ G1:    Well differentiated

___ G2:    Moderately differentiated

___ G3:    Poorly differentiated

___ G4:    Undifferentiated

 

EXTENT OF INVASION

___ Cannot be determined

___ Epithelium only (no invasion)

___ Invasion (deepest)

        ___ Cannot be determined

        ___ Into lamina propria

        ___ Into muscularis mucosae

        ___ Into submucosa

 

MARGIN (polypectomy only)

___ Not applicable

___ Uninvolved by tumor

        Distance of tumor from margin: ___ cm

___ Involved by tumor

 

BLOOD/VESSEL INVASION

___ Not applicable

___ Absent

___ Present

___ Indeterminate

 

ADDITIONAL PATHOLOGIC FINDINGS

___ None identified

___ Active colitis

___ Other (specify: _____________________)

COMMENT

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