Surgical Pathology Cancer Case Summary

LUNG:             Report

LUNG: Resection

MACROSCOPIC (check all that apply)

SPECIMEN TYPE

___ Major airway resection

___ Wedge resection

___ Segmentectomy

___ Lobectomy

___ Pneumonectomy

___ Other (specify:________________)

TUMOR SITE

___ Right lung

___ Upper lobe

___ Middle lobe

___ Lower lobe

___ Left lung

___ Upper lobe

___ Lower lobe

TUMOR SIZE: ___ x ___ x ___ cm

MICROSCOPIC (check all that apply)

HISTOLOGIC TYPE

___ Squamous cell carcinoma

___ Spindle cell (squamous) carcinoma

___ Small cell carcinoma

___ Oat cell carcinoma

___ Intermediate cell type carcinoma

___ Combined oat cell carcinoma

___ Adenocarcinoma

___ Acinar adenocarcinoma

___ Papillary adenocarcinoma

___ Bronchiolo-alveolar carcinoma

___ Solid carcinoma with mucus formation

___ Large-cell carcinoma

___ Giant cell carcinoma

___ Clear cell carcinoma

___ Adenosquamous carcinoma

___ Carcinoid tumor

___ Bronchial gland carcinoma

___ Adenoid cystic carcinoma

___ Mucoepidermoid carcinoma

___ Other(s) (specify:____________________)

___ Other (specify:__________________________)

HISTOLOGIC GRADE

___ GX: Cannot be assessed

___ G1: Well differentiated

___ G2: Moderately differentiated

___ G3: Poorly differentiated

___ G4: Undifferentiated

EXTENT OF INVASION

___ TX: Cannot be assessed, or tumor proven by presence of malignant cells in sputum or bronchial washings but not visualized by imaging or bronchoscopy

___ T0: No evidence of primary tumor

___ Tis: Carcinoma in situ

___ T1: Tumor 3 cm or less in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion more proximal than the lobar bronchus (ie, not in the main bronchus)

___ T2: Tumor with any of the following features of size or extent:
• Greater than 3 cm in greatest dimension
• involves main bronchus, 2 cm or more distal to the carina
• invades the visceral pleura
• associated with atelectasis or obstructive pneumonitis that extends to the hilar
region but does not involve the entire lung

___ T3: Tumor of any size that directly invades any of the following:
• chest wall (including superior sulcus tumors)
• diaphragm
• mediastinal pleura
• parietal pericardium

or

Tumor of any size in the main bronchus less than 2 cm distal to the carina but without involvement of the carina

or

Tumor of any size associated atelectasis or obstructive pneumonitis of the entire lung

___ T4: Tumor of any size that invades any of the following:
• mediastinum
• heart
• great vessels
• trachea
• esophagus
• vertebral body
• carina

or

Tumor of any size with separate tumor nodule(s) in same lobe

or

Tumor of any size with a malignant pleural effusion

MARGINS

___ Margins uninvolved by tumor

Distance of tumor from closest margin: ___ cm

(Specify margin:__________________________)

___ Margin(s) involved by tumor

___ Bronchial margin

___ Vascular margin

___ Parenchymal margin

___ Attached tissue margin

___ Others (specify: ______________________)

BLOOD/LYMPHATIC VESSEL INVASION

___ Absent

___ Present

___ Indeterminate

REGIONAL LYMPH NODES

___ NX: Cannot be assessed

___ N0: No regional lymph node metastasis

___ N1: Metastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph nodes, including intrapulmonary nodes involved by direct extension of the primary tumor

___ N2: Metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s)

___ N3: Metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene or supraclavicular lymph node(s)

DISTANT METASTASIS

___ MX: Cannot be assessed

___ M0: No distant metastasis

___ M1: Distant metastasis, includes separate tumor nodule(s) in a different lobe (ipsilateral or contralateral) (specify site(s): ______________________________________________)

ADDITIONAL PATHOLOGIC FINDINGS*

___ None identified

___ Metaplasia (type: _____________________)

___ Dysplasia

___ Inflammation (type: ___________________)

___ Other (specify: _______________________)

COMMENT

___________________________________________

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