Surgical Pathology Cancer Case Summary

GALLBLADDER:             Report

 

GALLBLADDER: Resection

MACROSCOPIC (check all that apply)

SPECIMEN TYPE

___ Cholecystectomy

___ Cholecystectomy with partial hepatectomy

___ Other (specify): ________________________

TUMOR SITE (check all that apply)

___ Fundus

___ Body

___ Neck

TUMOR SIZE: ___ x ___ x___ cm

ADDITIONAL PATHOLOGIC FINDINGS

___ Cholelithiasis

___ Polyp(s)

___ Other (specify): _________________________

 

MICROSCOPIC (check all that apply)

HISTOLOGIC TYPE

___ Carcinoma in situ

___ Papillary adenocarcinoma

___ Adenocarcinoma, intestinal type

___ Mucinous adenocarcinoma

___ Adenosquamous carcinoma

___ Small cell carcinoma

___ Other: __________________

HISTOLOGIC GRADE

___ 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

___ T1:     Tumor invades lamina propria or muscle layer

                  ___ T1a:   Tumor invades lamina propria

                  ___ T1b:   Tumor invades muscle layer

___ T2:     Tumor invades perimuscular connective tissue; no extension beyond serosa or into liver

___ T3:     Tumor perforates serosa (visceral peritoneum) or directly invades into one adjacent organ, or both (extension ≤ 2cm into liver)

___ T4:     Tumor extends > 2 cm into liver, and/or into two or more adjacent organs  (stomach, duodenum, colon, pancreas, omentum, extrahepatic bile ducts, any involvement of liver)

MARGINS

___ Not peritonealized surface (liver bed)

___ Cystic duct margin

___ Other (specify:__________________)

BLOOD/LYMPHATIC VESSEL INVASION

___ Absent

___ Present

___ Indeterminate

PERINEURAL INVASION

___ Absent

___ Present

___ Indeterminate

REGIONAL LYMPH NODES

___ NX:    Cannot be assessed

___ N0:    No regional lymph node metastasis

                  Number examined: ___

___ N1:    Metastasis in cystic duct, pericholedochal, and/or hilar lymph nodes (i.e., in the hepatoduodenal ligament)

___ N2:    Metastasis in peripancreatic (head only),  periduodenal, periportal, celiac, and/or superior mesenteric lymph nodes

DISTANT METASTASIS

___ MX:   Cannot be assessed

___ M0:    No distant metastasis

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

ADDITIONAL PATHOLOGIC FINDINGS

___ None identified

___ Dysplasia/adenoma

___ Acute cholecystitis

___ Cholelithiasis

___ Chronic cholecystitis

___ Other (specify: ____________________)

COMMENT

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