Surgical Pathology Cancer Case Summary (Checklist)

Specimen

___ Liver

___ Gallbladder

___ Other (specify): ______________________________

Procedure (select all that apply)

___ Wedge resection

___ Partial hepatectomy

^*___ Major hepatectomy (3 segments or more)

^*___ Minor hepatectomy (< 3 segments)

___ Total hepatectomy

___ Other (specify): ______________________________

___ Not specified

Tumor Size

Greatest dimension: ___ cm

^*Additional dimensions: ___ x ___ cm

___ Cannot be determined

Tumor Focality

___ Solitary (specify location): ______________________________

___ Multiple (specify location): ______________________________

Histologic Type

___ Cholangiocarcinoma

___ Combined hepatocellular and cholangiocarcinoma

___ Bile duct cystadenocarcinoma

___ Other (specify): ______________________________

Histologic Grade

___ Not applicable

___ GX: Cannot be assessed

___ GI: Well differentiated

___ GII: Moderately differentiated

___ GIII: Poorly differentiated

___ GIV: Undifferentiated

___ Other (specify): ______________________________

Tumor Growth Pattern

___ Mass forming

___ Periductal infiltrating

___ Mixed mass-forming and periductal infiltrating

___ Cannot be determined

Microscopic Tumor Extension (select all that apply)

___ Cannot be assessed

___ No evidence of primary tumor

___ Tumor confined to intrahepatic bile ducts histologically (carcinoma in situ)

___ Tumor confined to hepatic parenchyma

___ Tumor involves visceral peritoneal surface

___ Tumor directly invades adjacent organs other than gallbladder (specify): ______________________________

Margins (select all that apply)

Hepatic parenchymal margin

___ Cannot be assessed

___ Uninvolved by invasive carcinoma

Distance of invasive carcinoma from closest margin: __________ mm

Specify margin: ____________________

___ Involved by invasive carcinoma

Bile duct margin

___ Cannot be assessed

___ Uninvolved by invasive carcinoma

^*___ Dysplasia/carcinoma in situ not identified

^*___ Dysplasia/carcinoma in situ present

___ Involved by invasive carcinoma

Other margin

Specify margin: ______________________________

___ Cannot be assessed

___ Uninvolved by invasive carcinoma

___ Involved by invasive carcinoma

Lymph-Vascular Invasion

Venous (major vessel) invasion (V)

(invasion of right or left portal vein, 1 or more hepatic veins)

___ 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 (intraductal tumor)

___ pT1: Solitary tumor without vascular invasion

___ pT2a: Solitary tumor with vascular invasion

___ pT2b: Multiple tumors, ± vascular invasion

___ pT3: Tumor perforating visceral peritoneum or involving local extrahepatic structures by direct invasion

___ pT4: Tumor with periductal invasion

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)

^*___ Cirrhosis/severe fibrosis (Ishak fibrosis score 5-6)

^*___ Primary sclerosing cholangitis

^*___ Biliary stones

^*___ Chronic hepatitis (specify type): ______________________________

^*___ Other (specify): ______________________________

^*___ None identified

^*Ancillary Studies

^*Specify: ______________________________

^*Clinical History (select all that apply)

^*___ Cirrhosis

^*___ Primary sclerosing cholangitis

^*___ Inflammatory bowel disease

^*___ Hepatitis C infection

^*___ 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 Intrahepatic Bile Ducts.” Web posting date October 2009, www.cap.org.