Surgical Pathology Cancer Case Summary

URINARY BLADDER, URETER, RENAL PELVIS:             Report

URINARY BLADDER:

Cystectomy, partial or total; radical cystoprostatectomy; anterior exenteration

MACROSCOPIC (check all that apply)

SPECIMEN TYPE*

___ Partial cystectomy

___ Total cystectomy

___ Radical cystoprostatectomy

___ Anterior exenteration

TUMOR SITE (check all that apply)*

___ Trigone

___ Right lateral wall

___ Left lateral wall

___ Anterior wall

___ Posterior wall

___ Dome

TUMOR SIZE: ___x___x___cm*

TUMOR CONFIGURATION*

___ Papillary

___ Solid/nodule

___ Flat

___ Ulcerated

___ Indeterminate

OTHER ORGANS (if applicable, see optional Extended Synopsis)*

___ None

___ Urethra

___ Ureter(s)

___ Prostate

___ Seminal vesicles

___ Uterus

___ Vagina

___ Other(s) (specify)

MICROSCOPIC (check all that apply)

HISTOLOGIC TYPE

___ Urothelial (transitional cell) papilloma (WHO/ISUP, 1998; WHO, 1973)

___ Urothelial (transitional cell) papilloma, inverted type

___ Squamous cell papilloma

___ Papillary urothelial (transitional cell) neoplasm, low malignant potential (WHO/ISUP 1998)/grade I (WHO, 1973)

___ Urothelial (transitional cell) carcinoma in situ

___ Urothelial (transitional cell) carcinoma

___ Urothelial (transitional cell) carcinoma with the following:

___ Squamous differentiation

___ Glandular differentiation

___ Variant histology (specify)

___ Squamous cell carcinoma

___ Typical

___ Variant histology (specify)

___ Adenocarcinoma

___ Typical

___ Variant histology (specify)

___ Small cell carcinoma

___ Undifferentiated carcinoma (specify)

___ Carcinoma, mixed cell type (check all that apply)

___ Urothelial (transitional cell)

___ Squamous cell

___ Adenocarcinoma

___ Small cell carcinoma

___ Other (specify)

HISTOLOGIC GRADE

___ For urothelial carcinoma (WHO/ISUP, 1998)

___ Low grade

___ High grade

___ For adenocarcinoma and squamous carcinoma

___ GX: Cannot be assessed

___ G1: Well differentiated

___ G2: Moderately differentiated

___ G3-4: Poorly differentiated/undifferentiated

EXTENT OF INVASION

___ TX: Cannot be assessed

___ T0: No evidence of primary tumor

___ Ta: Noninvasive papillary carcinoma

___ Tis: Carcinoma in situ (“flat tumor”)

___ T1: Tumor invades subepithelial connective tissue

___ T2: Tumor invades muscularis propria

___ T2a: Tumor invades superficial muscle (inner half)

___ T2b: Tumor invades deep muscle

___ T3: Tumor invades perivesical tissue

___ T3a: Microscopically

___ T3b: Macroscopically (extravesicular mass)

___ T4: Tumor invades any of the following: prostate, uterus, vagina, pelvic wall, abdominal wall

___ T4a: Tumor invades prostate or uterus or vagina

___ T4b: Tumor invades pelvic wall or abdominal wall

REGIONAL LYMPH NODES

___ NX: Cannot be assessed

___ N0: No regional lymph node metastasis

Number examined: ___

___ N1: Metastasis in a single lymph node, 2 cm or less in greatest dimension

Number examined: ___

___ N2: Metastasis in a single lymph node, more than 2 cm but not more than 5 cm in greatest dimension, or multiple lymph nodes, none more than 5 cm in greatest dimension

Number examined: ___

Number involved: ___

___ N3: Metastasis in a lymph node more than 5 cm in greatest dimension

Number examined: ___

Total number involved (any size): ___

MARGINS

___ Margins uninvolved by tumor

Distance of tumor from closest margin: ___cm

(Specify margin: __________)

___ Margin(s) involved by tumor

___ Deep radial margin (soft tissue)

___ Ureteral margin

___ Left ureteral margin

___ Right ureteral margin

___ Urethral margin

___ Urachal margin (if applicable)

___ Uterine margin (if applicable)

___ Vaginal margin (if applicable)

___ Other (s) (specify)__________

BLOOD/LYMPHATIC VESSEL INVASION

___ Absent

___ Present

___ Indeterminate (see comment)

DISTANT METASTASIS

___ MX: Cannot be assessed

___ M0: No distant metastasis

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

___________________________________________

ADDITIONAL PATHOLOGIC FINDINGS*

___ Urothelial dysplasia (low grade intraurothelial neoplasia)

___ Focal

___ Multifocal

___ Inflammation/regenerative changes

___ Therapy related changes

___ Cystitis cystica glandularis

___ Keratinizing squamous metaplasia

___ Intestinal metaplasia

___ Other (specify)

COMMENTS

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