Surgical Pathology Cancer Case Summary (Checklist)

Specimen (select all that apply)

___Common bile duct

___Right hepatic duct

___Left hepatic duct

___Junction of right and left hepatic ducts

___Common hepatic duct

___Cystic duct

___Not specified

Other organs received

___Stomach

___Duodenum

___Pancreas

___Ampulla

___Gallbladder

___Other (specify):____________________

Procedure

___Pancreaticoduodenectomy

___Segmental resection of bile duct(s)

___Choledochal cyst resection

___Other (specify):____________________

___Not specified

Tumor Site (select all that apply)

___Common bile duct

___Extrapancreatic

___Intrapancreatic

___Other (specify):____________________

___Not specified

Tumor Size

Greatest dimension: _____cm

^*Additional dimensions: _____ x _____ cm

___Cannot be determined

Histologic Type

___Adenocarcinoma (not otherwise characterized)

___Papillary adenocarcinoma

___Mucinous adenocarcinoma

___Clear cell adenocarcinoma

___Signet ring cell carcinoma

___Adenosquamous carcinoma

___Squamous cell carcinoma

___Small cell carcinoma

___Large cell neuroendocrine carcinoma

___Biliary cystadenocarcinoma

___Other (specify):____________________

___Carcinoma, type cannot be determined

Histologic Grade

___Not applicable

___GX: Cannot be assessed

___G1: Well differentiated

___G2: Moderately differentiated

___G3: Poorly differentiated

___G4: Undifferentiated

Microscopic Tumor Extension (select all that apply)

___Carcinoma in situ

___Tumor confined to bile duct histologically

___Tumor invades beyond wall of bile duct

___Tumor invades duodenum

___Tumor invades pancreas

___Tumor invades gallbladder

___Tumor invades other adjacent structures (specify):____________________

Margins (select all that apply)

Segmental resection specimen

___Cannot be assessed

___Margins uninvolved by invasive carcinoma

Distance of invasive carcinoma from closest margin: _____ mm

Specify margin:____________________

___Margins involved by invasive carcinoma

___Proximal bile duct margin

___Distal bile duct margin

___Other (specify):____________________

___Dysplasia/carcinoma in situ not identified at bile duct margin

___Dysplasia/carcinoma in situ present at bile duct margin

Pancreaticoduodenal resection specimen

Proximal margin (gastric or duodenal)

___Cannot be assessed

___Uninvolved by invasive carcinoma

___Involved by invasive carcinoma

Distal margin (distal duodenal)

___Cannot be assessed

___Uninvolved by invasive carcinoma

___Involved by invasive carcinoma

Pancreatic retroperitoneal 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 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 confined to bile duct histologically

___pT2: Tumor invades beyond wall of bile duct

___pT3: Tumor invades gallbladder, pancreas, duodenum, or other adjacent organs without involvement of celiac axis or superior mesenteric artery

___Tumor involves celiac axis or superior mesenteric artery

Regional lymph nodes (pN)

___pNX: Cannot be assessed

___pN0: No regional lymph node metastasis

___pN1: Regional lymph node metastasis

Specify: Number examined:_____

Number involved:_____

Distant metastasis (pM)

___Not applicable

___pM1: Distant metastasis

^*Specify site(s), if known:____________________

^*Additional Pathologic Findings (select all that apply)

^*___None identified

^*___Choledochal cyst

^*___Dysplasia

^*___Primary sclerosing cholangitis (PSC)

^*___Stones

^*___Other (specify):____________________

^*Ancillary Studies

^*Specify:____________________

^*Clinical History (select all that apply)

^*___Primary sclerosing cholangitis

^*___Inflammatory bowel disease

^*___Biliary stones

^*___Other (specify):____________________

^* 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 Distal Extrahepatic Bile Ducts.” Web posting date October 2009, www.cap.org. Protocol applies to all invasive carcinomas of the distal extrahepatic bile ducts. Well-differentiated neuroendocrine neoplasms (carcinoid tumors) are not included. Carcinomas of the perihilar bile ducts are not included.