Surgical Pathology Cancer Case Summary (Checklist)

Specimen (select all that apply)

____ Head of pancreas

____ Body of pancreas

____ Tail of pancreas

____ Duodenum

____ Stomach

____ Common bile duct

____ Gallbladder

____ Spleen

____ Adjacent large vessels

____ Portal vein

____ Superior mesenteric vein

____ Other large vessel (specify): ______________________________

____ Other (specify): ______________________________

____ Not specified

____ Cannot be determined

Procedure

____ Pancreaticoduodenectomy (Whipple resection), partial pancreatectomy

____ Pancreatoduodenectomy (Whipple resection), total pancreatectomy

____ Partial pancreatectomy, pancreatic body

____ Partial pancreatectomy, pancreatic tail

____ Other (specify): ______________________________

____ Not specified

Tumor Site (select all that apply)

____ Pancreatic head

____ Uncinate process

____ Pancreatic body

____ Other (specify): ______________________________

____ Not specified

Tumor Size

Greatest dimension: __________ cm

^*Additional dimensions: _________ × __________ cm

____ Cannot be determined

Histologic Type (select all that apply)

____ Ductal adenocarcinoma

____ Mucinous noncystic carcinoma

____ Signet ring cell carcinoma

____ Adenosquamous carcinoma

____ Undifferentiated (anaplastic) carcinoma

____ Undifferentiated carcinoma with osteoclast-like giant cells

____ Mixed ductal-endocrine carcinoma

____ Serous cystadenocarcinoma

____ Noninvasive

____ Invasive

____ Intraductal papillary-mucinous carcinoma

____ Noninvasive

____ Invasive

____ Acinar cell carcinoma

____ Acinar cell cystadenocarcinoma

____ Mixed acinar-endocrine carcinoma

____ Other (specify):______________________________

Histologic Grade (ductal carcinoma only)

____ Not applicable

____ 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 is confined to pancreas

____ Tumor invades ampulla of Vater or sphincter of Oddi

____ Tumor invades duodenal wall

____ Tumor invades peripancreatic soft tissues

^*____ Tumor invades retroperitoneal soft tissue

^*____ Tumor invades mesenteric adipose tissue

^*____ Tumor invades mesocolon

^*____ Tumor invades other peripancreatic soft tissue (specify):______________________________

____ Tumor invades extrapancreatic common bile duct

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

Margins (select all that apply)

____ Cannot be assessed

____ Margins uninvolved by invasive carcinoma

Distance of invasive carcinoma from closest margin:____________ mm

^*Specify margin (if possible):______________________________

____ Margins uninvolved by carcinoma in situ

____ Margin(s) involved by carcinoma in situ

____ Carcinoma in situ present at common bile duct margin

____ Carcinoma in situ present at pancreatic parenchymal margin

____ Margin(s) involved by invasive carcinoma

____ Uncinate process (retroperitoneal) margin (nonperitonealized surface of uncinate process)

____ Distal pancreatic margin

____ Common bile duct margin

____ Proximal pancreatic margin

____ Other (specify):______________________________

^*____ Invasive carcinoma involves posterior retroperitoneal surface of pancreas

Treatment Effect (applicable to carcinomas treated with neoadjuvant therapy) (select all that apply)

____ No prior treatment

____ Present

^*____ No residual tumor (complete response, grade 0)

^*____ Marked response (grade 1, minimal residual cancer)

^*____ Moderate response (grade 2)

____ No definite response identified (grade 3, poor or no response)

____ Not known

Lymph-Vascular 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 pancreas, ≤ 2 cm in greatest dimension

____ pT2: Tumor limited to pancreas, > 2 cm in greatest dimension

____ pT3: Tumor extends beyond pancreas but without involvement of celiac axis or superior mesenteric artery

____ pT3: 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

^*____ Pancreatic intraepithelial neoplasia (highest grade: PanIN ____________)

^*____ Chronic pancreatitis

^*____ Acute pancreatitis

^*____ Other (specify):______________________________

^* Ancillary Studies

^*Specify:______________________________

^*Clinical History (select all that apply)

^*____ Neoadjuvant therapy

^*____ Familial pancreatitis

^*____ Familial pancreatic cancer syndrome

^*____ Other (specify):______________________________

^*____ Not specified

^* 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 Exocrine Pancreas.” Web posting date October 2009, www.cap.org. Protocol applies to all epithelial tumors of the exocrine pancreas. Endocrine tumors and tumors of the ampulla of Vater are not included.