Surgical Pathology Cancer Case Summary
COLON AND RECTUM: Report
COLON AND RECTUM: Cytology/Biopsy
MACROSCOPIC (check all that apply)
SPECIMEN TYPE
___ Incisional biopsy
___ Excisional biopsy (polypectomy)
TUMOR SITE
___ Cecum
___ Right (ascending) colon
___ Hepatic flexure
___ Transverse colon
___ Splenic flexure
___ Left (descending) colon
___ Sigmoid colon
___ Rectum
___ Unknown
POLYPECTOMY ONLY
Size: ___ x ___ x ___
Polyp configuration:
___ Pedunculated
___ Stalk (stalk length: ___ cm)
___ No stalk
___ Sessile
MICROSCOPIC (check all that apply)
HISTOLOGIC TYPE
___ Cannot be determined
___ Adenocarcinoma in situ/severe dysplasia
___ Adenocarcinoma
___ Mucinous adenocarcinoma (>50% mucinous)
___ Signet ring cell carcinoma (>50% signet ring cells)
___ Undifferentiated carcinoma
___ Other:___________________
HISTOLOGIC GRADE (if applicable to tumor type)
___ Not applicable
___ GX: Cannot be assessed
___ G1: Well differentiated (>95% gland forming)
___ G2: Moderately differentiated (50-95% gland forming)
___ G3: Poorly differentiated (5-49% gland forming)
___ G4: Undifferentiated (<5% gland forming)
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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