Surgical Pathology Cancer Case Summary

COLON AND RECTUM:             Report

COLON AND RECTUM: Excision

Other identifiers:

MACROSCOPIC (check all that apply)

SPECIMEN TYPE

___ Right hemicolectomy (length: ___ cm)

___ Transverse colectomy (length: ___ cm)

___ Left hemicolectomy (length: ___ cm)

___ Sigmoidectomy (length: ___ cm)

___ Rectal resection (low anterior resection) (length: ___ cm)

___ Total abdominal colectomy (length: ___ cm)

___ Abdominoperineal resection

___ Other (specify: __________________________)

TUMOR SITE

___ Cecum

___ Right (ascending) colon

___ Hepatic flexure

___ Transverse colon

___ Splenic flexure

___ Left (descending) colon

___ Sigmoid colon

___ Rectum

TUMOR CONFIGURATION:

___ Exophytic (polypoid)

___ Infiltrative

___ Ulcerating

___ Other (specify: ______________________)

TUMOR SIZE: ___ x ___ x ___ cm

ADDITIONAL PATHOLOGIC FINDINGS

___ None identified

___ Polyps (number: ___)

___ Chronic proctocolitis

___ Patchy (location: _______________)

___ Confluent

___ Other (specify: __________________________)

MICROSCOPIC (check all that apply)

HISTOLOGIC TYPE

___ 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

___ TX: Cannot be assessed

___ T0: No evidence of primary tumor

___ Tis: Carcinoma in situ

___ Intraepithelial (no invasion)

___ Invasion of lamina propria

___ Invasion of muscularis mucosae

___ T1: Tumor invades submucosa

___ T2: Tumor invades muscularis propria

___ T3: Tumor invades through the muscularis propria into the subserosa or the nonperitonealized pericolic or perirectal soft tissues

___ Invades < 5 mm beyond the border of the muscularis propria

___ Invades > 5 mm beyond the border of the muscularis propria

___ T4a: Tumor directly invades other organs or structures

___ T4b: Tumor penetrates the visceral peritoneum

MARGINS

Proximal margin

___ Uninvolved

___ Involved by tumor

Distal margin

___ Uninvolved

___ Involved by tumor

Deep (radial) margin

___ Not applicable

___ Uninvolved

___ Involved by tumor

Distance of tumor from closest margin: ___ cm

(specify margin: __________________________)

BLOOD/LYMPHATIC (SMALL) VESSEL INVASION

___ Absent

___ Indeterminate

___ Present

___ Intramural

___ Extramural

VENOUS (LARGE) VESSEL INVASION

___ Absent

___ Present

___ Intramural

___ Extramural

___ Indeterminate

PERINEURAL INVASION

___ Absent

___ Present

TUMOR BORDER CONFIGURATION

___ Pushing

___ Infiltrating

PERITUMORAL LYMPHOCYTIC RESPONSE

___ None

___ Mild to moderate

___ Marked (including Crohn’s-like response)

REGIONAL LYMPH NODES

___ NX: Cannot be assessed

___ N0: No regional lymph node metastasis

Number examined: ___

___ N1: Metastasis in 1-3 lymph nodes

Number examined: ___

Number involved: ___

___ N2: Metastasis in 4 or more lymph nodes

Number examined: ___

Number involved: ___

DISTANT METASTASIS

___ MX: Cannot be assessed

___ M0: No distant metastasis

___ M1: Distant metastasis (site(s):_____________

_________________________________________)

ADDITIONAL PATHOLOGIC FINDINGS

___ None identified

___ Adenoma(s)

___ Chronic ulcerative proctocolitis

___ Crohn’s disease

___ Dysplasia

___ Other polyps (type(s):__________________)

___ Other (specify: _____________________)

COMMENT

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