Surgical Pathology Cancer Case Summary (Checklist)

Specimen (select all that apply)

___Gallbladder

___Liver

___Extrahepatic bile duct

___Other (specify):____________________

___Not specified

Procedure

___Simple cholecystectomy (laparoscopic or open)

___Radical cholecystectomy (with liver resection and lymphadenectomy)

___Other (specify):____________________

___Not specified

Tumor Site (select all that apply)

___Fundus

___Body

___Neck

___Cystic duct

___Free peritoneal side of gallbladder

___Hepatic side of gallbladder

___Cannot be determined

___Other (specify):____________________

___Not specified

Tumor Size

Greatest dimension: __________ cm

^*Additional dimensions: __________ x __________ cm

___Cannot be determined

Histologic Type

___Adenocarcinoma, not otherwise specified

___Papillary adenocarcinoma

___Adenocarcinoma, intestinal type

___Mucinous carcinoma

___Signet ring cell carcinoma

___Clear cell carcinoma

___Squamous cell carcinoma

___Adenosquamous carcinoma

___Small cell carcinoma

___Undifferentiated carcinoma

___Carcinoma, not otherwise specified

___Carcinosarcoma

___Other (specify):__________

Microscopic Tumor Extension

___Tumor invades lamina propria

___Tumor invades muscle layer

___Tumor invades perimuscular connective tissue; no extension beyond serosa or into liver

___Tumor perforates serosa (visceral peritoneum)

___Tumor directly invades liver

___Tumor directly invades extrahepatic bile ducts

___Tumor directly invades other adjacent organ or structure, such as stomach, duodenum, colon, pancreas, or omentum (specify):____________________

Margins (select all that apply)

___Cannot be assessed

___Margins uninvolved by invasive carcinoma

Distance of invasive carcinoma from closest margin: _____ mm

Specify margin:________________

___Margins involved by invasive carcinoma

Specify margin(s):________________

___Cystic duct margin uninvolved by intramucosal carcinoma

___Cystic duct margin involved by intramucosal carcinoma

^* Lymph-Vascular Invasion

^*___Not identified

^*___Present

^*Perineural Invasion

^*___Not identified

^*___Present

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 invades lamina propria or muscular layer

___pT1a: Tumor invades lamina propria

___pT1b: Tumor invades muscle layer

___pT2: Tumor invades perimuscular connective tissue; no extension beyond serosa or into liver

___pT3: Tumor perforates serosa (visceral peritoneum) &/or directly invades liver &/or 1 other adjacent organ or structure, such as the stomach, duodenum, colon, pancreas, omentum, or extrahepatic bile ducts

___PT4: Tumor invades main portal vein or hepatic artery or invades 2 or more extrahepatic organs or structures

Regional lymph nodes (pN)

___pNX: Cannot be assessed

___pN0: No regional lymph node metastasis

___pN1: Metastases to nodes along cystic duct, common bile duct, hepatic artery, &/or portal vein

Specify: Number examined:_____

Number involved:_____

___pN2: Metastases to periaortic, cervical, superior mesentery artery, &/or celiac artery lymph nodes

Specify: Number examined:_____

Number involved:_____

Distant metastasis (pM)

___Not applicable

___pM1: Distant metastasis

^*Specify site(s), if 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 Gallbladder.” Web posting date October 2009, www.cap.org. Protocol applies to all invasive carcinomas of the gallbladder and cystic duct, including those showing focal endocrine differentiation. Well-differentiated neuroendocrine neoplasms (carcinoid tumors) are not included.