Surgical Pathology Cancer Case Summary (Checklist)

Specimen (select all that apply)

____ Ampulla of Vater

____ Stomach

____ Head of pancreas

____ Duodenum

____ Common bile duct

____ Gallbladder

____ Other (specify): ______________________________

____ Not specified

Procedure

____ Ampullectomy

____ Pancreaticoduodenectomy (Whipple resection)

____ Other (specify): ______________________________

____ Not specified

Tumor Site

____ Intraampullary

____ Periampullary

____ Papilla of Vater (junction of ampullary and duodenal mucosa)

____ Other (specify): ______________________________

____ Cannot be determined

____ Not specified

^*Tumor Size

Greatest dimension: ____________ x ____________ cm

^*Additional dimensions: ____ x ____ cm

____ Cannot be determined

Histologic Type

____ Adenocarcinoma (not otherwise characterized)

____ Papillary adenocarcinoma

____ Adenocarcinoma, intestinal type

____ Mucinous adenocarcinoma

____ Clear cell adenocarcinoma

____ Signet ring cell carcinoma

____ Adenosquamous carcinoma

____ Squamous cell carcinoma

____ Small cell carcinoma

____ Other (specify): ______________________________

____ Carcinoma, not otherwise specified

Histologic Grade

____ Not applicable (histologic type not usually graded)

____ GX: Cannot be assessed

____ G1: Well differentiated

____ G2: Moderately differentiated

____ G3: Poorly differentiated

____ G4: Undifferentiated

____ Other (specify): ______________________________

Microscopic Tumor Extension (select all that apply)

____ Cannot be assessed

____ No evidence of primary tumor

____ Carcinoma in situ

____ Tumor limited to ampulla of Vater or sphincter of Oddi

____ Tumor invades duodenal wall

____ Tumor invades pancreas

____ Tumor invades peripancreatic soft tissues

____ Tumor invades extrapancreatic common bile duct

____ Tumor invades other adjacent organs or structures other than pancreas (specify): ______________________________

Margins (select all that apply)

Ampullectomy specimen

____ Cannot be assessed

____ Margins uninvolved by invasive carcinoma

Distance of invasive carcinoma from closest margin: ____________ mm

Specify margin (if possible): ______________________________

____ Margins involved by invasive carcinoma

Specify margin (if possible): ______________________________

____ Not applicable

Pancreaticoduodenal resection specimen

Proximal mucosal margin (gastric or duodenal)

____ Cannot be assessed

____ Uninvolved by invasive carcinoma

____ Involved by invasive carcinoma

____ Intramucosal carcinoma/adenoma not identified at proximal margin

____ Intramucosal carcinoma/adenoma present at proximal margin

Distal margin (distal duodenal or jejunal)

____ Cannot be assessed

____ Uninvolved by invasive carcinoma

____ Involved by invasive carcinoma

____ Intramucosal carcinoma/adenoma not identified at distal margin

____ Intramucosal carcinoma/adenoma present at distal margin

Pancreatic retroperitoneal (uncinate) margin

____ Not applicable

____ Cannot be assessed

____ Uninvolved by invasive carcinoma

____ Involved by invasive carcinoma (tumor present 0-1 mm from margin)

Bile duct margin

____ Not applicable

____ Cannot be assessed

____ Margin uninvolved by invasive carcinoma

____ Margin involved by invasive carcinoma

Distal pancreatic resection margin

____ Not applicable

____ Cannot be assessed

____ Margin uninvolved by invasive carcinoma

____ Margin involved by invasive carcinoma

If all margins uninvolved by invasive carcinoma

Distance of invasive carcinoma from closest margin: ____ mm OR ____ cm

Specify margin: ______________________________

Lymph-Vascular Invasion

____ Not identified

____ Present

____ Indeterminate

^*Perineural Invasion

^* ____ Not identified

^* ____ Present

^* ____ Indeterminate

Pathologic Staging (pTNM)

TNM descriptors (required only if applicable) (select all that apply)

____ m (multiple primary tumors)

____ r (recurrent)

____ y (post-treatment)

Primary tumor (pT)

____ pTX: Cannot be assessed

____ pT0: No evidence of primary tumor

____ pTis: Carcinoma in situ

____ pT1: Tumor limited to ampulla of Vater or sphincter of Oddi

____ pT2: Tumor invades duodenal wall

____ pT3: Tumor invades pancreas

____ pT4: Tumor invades peripancreatic soft tissues or other adjacent organs or structures

Regional lymph nodes (pN)

____ pNX: Cannot be assessed

____ pN0: No regional lymph node metastasis

____ Regional lymph node metastasis

Specify: Number examined: ____________

Number involved: ___________

Distant metastasis (pM)

____ Not applicable

____ pM1: Distant metastasis

^*Specify sites (if known):______________________________

^* Additional Pathologic Findings (select all that apply)

^* ____ None identified

^* ____ Dysplasia/adenoma

^* ____ Other (specify):

^* Ancillary Studies

^*Specify: ______________________________

^* ____ Not performed

^*Clinical History (select all that apply)

^* ____ Familial adenomatous polyposis coli

^* ____ Other (specify): ______________________________

^* ____ Not known

^* Data elements with asterisks are not required. However, these elements may be clinically important but are not yet validated or regularly used in patient management. Adapted with permission from College of American Pathologists, “Protocol for the Examination of Specimens from Patients with Carcinoma of the Ampulla of Vater.” Web posting date October 2009, www.cap.org. Protocol applies to all intra-ampullary, periampullary, and mixed intra- and periampullary carcinomas. Well-differentiated neuroendocrine neoplasms (carcinoid tumors) are not included.