Colon Ca- Path Report
 
Colon Resection   AJCC 6th Edition; CAP 2005 Lakeridge Health Pathology 
      2007-05-10 Cancer Case Summary
Diagnosis Example:   Sigmoid Colon - Adenocarcinoma, See Pathology Cancer Case Summary
Microscopic:      
# Report Header   Dictation Options Note
Surgical Pathology Cancer Case Summary  
  FROM GROSS DESCRIPTION      
1 Neo-adjuvant therapy   Yes - XRT  
      Yes - Chemo  
      Yes - XRT and Chemo  
      No  
      Unknown  
2 Clinical Staging   Not provided  
  T   Dictate as written by surgeon on request form  
  N   Dictate as written by surgeon on request form  
  M   Dictate as written by surgeon on request form  
3 Specimen Type   Segmental resection (Rt, Transv, Rectosig)  
      TME (Total Mesorectal Excision)  
      Abdominal perineal (APR)  
4 Tumour Site   Colon, NOS Sigmoid: upper 1/3; covered by peritoneum
      Appendix Rectosig: mid 1/3; half-covered w peritoneum
      Cecum Rectum: lower 1/3; no peritoneal covering
      Ascending colon  
      Hepatic flexure of colon  
      Transverse colon  
      Splenic flexure of colon  
      Descending colon  
      Sigmoid colon    
      Rectosigmoid junction  
      Rectum, NOS  
      Overlapping lesion of colon  
      For APR:  Tumour __cm above dentate line  
5 Tumour Relation to Peritoneal Reflection (Rectosigmoid)   __ cm Above / Below or Straddles Anterior Measure from tumour border to perit. margin on Anterior aspect
6 Mesorectum      
  Criteria of Nagtegaal  2002   Complete / Near complete / Incomplete TME criteria
      Not applicable Mesorectum applies to rectosigmoid and APR
        TME Examples (McLean)
7 Tumour Dimensions (cm)      
  Length      
  Width      
  Thickness      
8 Tumour Configuration   Polypoid (Exophytic)  
      Ulcerating  
      Infiltrative (linitis plastica-like)  
9 Tumour Perforation   Present / Absent pT4 if present
  FROM MICROSCOPIC EXAM      
10 Histologic Type   Severe Dysplasia preferred terminology (vs AdenoCIS)
      Adenocarcinoma WHO classification
      Mucinous Carcinoma > 50% mucinous
      Signet Ring Carcinoma >50% signet ring
      Small cell ca Oat cell
      Undifferentiated ca < 5% composed of glands
      Medullary Assoc. w MSI-H
      Other (specify) (Squamous, Adenosquamous)
11 Histologic Grade     WHO criteria for Grading:
      Well differentiated >95% gland forming
      Moderately differentiated 50-95% gland forming
      Poorly differentiated 5-50% gland forming; or mucinous or signet ring ca
      Undifferentiated, anaplastic <5% gland forming
      no determined or cannot be determined  
12 Extent of Disease   Submucosa  
      Into muscularis propria  
      Through muscularis propria  
      Subserosal tissue/fat  
      Mesentery  
      Pericolic fat  
      Retroperitoneal fat  
      Great omentum or gastrocolic ligament  (from transverse colon or flexures)
      Adherence to other organs or structures but no tumour found in adhesions  
      Serosa (visceral peritoneium)  
      Involvement of other organs or structures, specify  
      No evidence of primary tumour  
      Unknown extension; primary tumour cannot be assessed  
13 Margins Clearance (Invasive)      
  Proximal   Involved / Not involved w __cm clearance  
  Distal   Involved / Not involved w __cm clearance 1 cm (T1, T2) ; 2 cm (T3, T4) clearance is adequate distal margin for Low Anterior Resection (CAP)
  Circumferential   Involved / Not involved __cm clearance All colon segments except Transverse; Tumour within =< 1 mm of CRM, incl. LN mets or direct extension are "positive" margin (CAP)
  Mesenteric   Involved / Not involved __cm clearance Transverse colon
  Closest Margin   Specify margin  
14 Margins Clearance (In situ)   NA (No in situ tumour identified)  
      If in situ/ high grade dysplasia present,  specify margins Involved or Uninvolved w. clearance  
15 Perineural Invasion   Absent / Present  
16 Venous (Large Vessel) Invasion Absent / Indeterminate V0
      Present: Intramural or Extramural V1
      Gross Venous inv. V2
17 Lymphatic (Small Vessel) Invasion Absent / Indeterminate L0
      Present: Intramural or Extramural L1
18 Tumour Border Configuration   Pushing / Infiltrating Infiltrating border = dissection of tumor (1)through musc propria wo stromal response OR (2)by small glands or cords of cells in mesentery OR (3)perineural inv.
19 Intra / Peri Tumoural Lymphocytes None  
      Mild to Mod Intra (Peri) tumoral response (specify intra vs peri tumoral) Favourable prognosis for peritumoral response. Intratumoral response assoc w MSI-H & Medullary Ca
      Marked  Intra (Peri) tumoral response  
20 Lymph nodes - Location   LN(s) cannot be assessed e.g. No LN found
      No LNs involved (Loc'n NA) LN present and not involved report 00
      Regional LNs  
      Distant LNs, NOS (METS) Stage 4
21 Lymph nodes Total Examined     12 LN recommended
      0 - No LNs examined  
      __ # (state number up to 89 LN) Specify # LN examined up to 89
      __# (state 90 for 90 or more LN) >=90 LN, report as '90'
      No LN removed but aspiration performed  
      Unknown if LNs examined  
22 LN Total Involved   No LNs examined Smooth deposits in fat are LN mets; irreg deposits when single, are T3; when multiple, are "LN mets"
      All LNs examined negative  
      __ # positive up to 89, report number
      report 90 if 90 or more LN pos 90 or more LNs positive
      Positive LNs - number unspecified  
      Unknown if LNs are positive; not applicable  
23 Distant Metastasis   Cannot be assessed  
      No distant mets  
      Distant metastasis  
24 Other Features / Tissues   Specify  
25 Correlation with Operative Consult   NA / Agrees / Disagrees Operative consult w/wo Frozen Section; Explain if no correlation
26 Correlation with Prior Biopsy   NA / Agrees / Disagrees with Surg # Explain if no correlation
27 Internal Consultation   Not applicable / Pathologist name  
28 Comments   Not applicable or state  
29 Behaviour Code   No malignancy found  
      Uncertain/borderline malignancy  
      In situ  
      Invasive  
      Metastatic  
      Invsaive, uncertain primary or metastatic  
30 Additional pTNM Descriptors   e.g. r, y, m Recurrent; After Rx; Multiple coding
31 AJCC Staging 6th Ed      
  Tumour pTX Cannot be assessed  
    pT0 No evidence of primary tumour  
    pTis High Grade Dysplasia; no invasion Lam Prop  
    pT1 Invades submucosa  
    pT2 Invades muscularis propria  
    pT3 Invades into subserosa or into non- peritonealized pericolic or perirectal tissues Smooth deposits in fat are LN mets; irreg deposits when single, are T3; when multiple, are "LN mets"
    pT3a/b Invades =< 5 mm beyond Musc. propria Extension in Vn or Lymphatic does affect pT classification
    pT3c/d Invades > 5 mm beyond Musc. propria  
    pT4a Tumour invades adjacent structures Extension to adjacent bowel does not affect pT classification (e.g. cecum into TI)
    pT4b Tumour penetrates visceral peritoneum Defined by ink touching tumour
  LN pNX Cannot be assessed  
    pN0 Negative (# LN examined) Note re Isolated Tumour Cells (<0.2 mm)
    pN1 1-3 LN mets micromet 0.21-2.0 mm dia
    pN2 4 or more LN mets  
  Mets pMX Cannot be assessed  
    pM0 No distant mets  
    pM1 Distant metastasis  
  Histologic Grade   Grade cannot be assessed  
      Low Grade  
      High Grade  
  Residual Tumour pRX Residual tumour cannot be assessed  
    pR0 All margins are free of tumor  
    pR1 Incomplete resection, microscopic tumour present at margin  
    pR2 Incomplete resection, gross tumour present at margin  
  Venous /  Lymphatic Invasion   V, L - see note  
32 Lcode   L866