Anus Resection   AJCC 6th Edition; CAP 2005  
      2006-08-04 Cancer Case Summary
Note: If tumour center > 2 cm proximal to the dentate line, report as Rectal Ca using Colon report; For Skin Cancer, use Skin Report
Diagnosis Example: Anus (APR Resection) - Basaloid Carcinoma, See Cancer Case Summary
# Report Header   Dictation Options Note
Surgical Pathology Cancer Case Summary  
1 Specimen Type   See note above re checklist to use State all tissues received
      Transanal disc excision  
      Abdominal Perineal Resection  
2 Tumour Site   ___ cm [proximal / distal] to the dentate line  
      Anterior wall / Anal margin  
3 Tumour Size   Length x Width x Thickness cm  
4 Tumour Configuration   Polypoid, Ulcerating, Infiltrative If polypoid, sessile or pedunculated (length of pedicle). For APR, apparent depth of inv.
5 Histologic Type     WHO classification
      Intraepithelial Neoplasia Squamous, Glandular, Pagets
        Note re Anal Pagets and CK7/20
      Squamous Cell Carcinoma Anal transition zone tumours usually are a mix of Lg Cell Non-keratinizing SCC and Basaloid SCC. The WHO no longer subclassifies SCC. "Cloacogenic" / "Transitional" terms are no longer used
      Verrucous SCC  Better prognosis than SCC
      SCC with mucinous microcysts Poorer prognosis than SCC
      Mucinous Adenocarcinoma  
      Small cell and Undifferentiated Ca High Grade Neuroendocrine Ca
6 Histologic Grade GX Grade cannot be assessed For AdenoCa, use
    G1 Well differentiated >95% glands
    G2 Moderately differentiated 50 - 95% glands
    G3 Poorly differentiated 0 - 49% glands
    G4 Undifferentiated Small cell ca, Undiff. Ca.
7 Extent of Tumour pTX Cannot be assessed Carcinoma in situ
    pT0 No evidence of primary tumour  
    pTis Carcinoma in-situ  
    pT1 =< 2 cm greatest dim  
    pT2 2.1 - 5.0 cm greatest dim.  
    pT3 >5 cm greatest dim.  
    pT4 Tumour invades adjacent structures  
8 Proximal Margin   Uninvolved by invasive ca  
      CIS / Adenoma present/absent  
      Involved by invasive ca  
9 Distal Margin   Uninvolved by invasive ca  
      CIS / Adenoma present/absent  
      Involved by invasive ca  
10 Circumferential (Radial) Margin Uninvolved by invasive ca  
      Involved by invasive ca  
11 Distance of Invasive Ca from closest margin   __ mm from __ (specify margin)  
12 Perineural Invasion   Absent / Present  
13 Venous (Large Vessel) Invasion   Absent / Indeterminate V0
      Present: Intramural or Extramural V1
      Gross Venous inv. V2
14 Lymphatic (Small Vessel) Invasion   Absent / Indeterminate L0
      Present: Intramural or Extramural L1
15 Regional lymph nodes   # involved / Total #  & location  
    pNX Cannot be assessed  
    pN0 Negative (# LN examined) Note re Isolated Tumour Cells
    pN1 Perirectal LN mets  
    pN2 Unilateral int. iliac and/or inguinal LN mets  
    pN3 Perirectal and Inguinal LN mets and / or bilateral int. iliac and / or inguinal LN mets  
16 Distant Metastasis pMX Cannot be assessed  
    pM1 Distant metastasis (specify)  
17 Additional Findings   Non-neoplastic bowel is unremarkable  
      Other (specify)  
18 Other tissues/organs   Specify and correlate  
19 Correlation with Operative Consult (FS)   NA / Agrees / Disagrees Explain if no correlation
20 Correlation with prior biopsy   NA / Agrees / Disagrees with Surg # Explain if no correlation
21 Internal Consultation   Pathologist name / not applicable  
22 Comments   Not applicable or state  
23 pTNM AJCC 6th Ed     Recurrent; After Rx; Multiple coding
  Tumour   TX Primary Tumour cannot be assessed
      T0 No evidence of primary tumour
      Tis Carcinoma in situ
      T1 =< 2 cm greatest dim
      T2 2.1 - 5.0 cm greatest dimension
      T3 > 5.0 cm greatest dimension
      T4 Directly invades other organs. Direct inv. of the rectal wall, perirectal skin, subcutaneous tiss or the sphincter muscle is NOT T4
  Nodes   NX LN cannot be assessed
      N0 No LN mets
      N1 Perirectal LN mets
      N2 Unilateral internal iliac and/or inguinal LN
      N3 Unilateral Perirectal and inguinal LN and/or bilateral internal iliac and/or inguinal LN
  Mets   MX Distant metastasis cannot be assessed
      M0 No Distant metastasis
      M1 Distant metastasis
  Histologic Grade   G1 Well differentiated
      G2 Moderately differentiated
      G3 Poorly differentiated
      G4 Undifferentiated
  Residual Tumour   RX Residual tumour cannot be assessed
      R0 All margins are free of tumor
      R1 Incomplete resection, microscopic tumour present at margin
      R2 Incomplete resection, gross tumour present at margin
  Venous /  Lymphatic Invasion   V, L - see note