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A1 Adrenal Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer 49 Staging Manual, 6th Ed.)

Tumor size: A2 ____ x ____ x ____ cm

Tumor weight: A3 ____ gm

Histologic type: A4a Cortical adenomaA4b Cortical carcinomaA4c PheochromocytomaA4d Other: _________

Staging: A5a I: Confined to gland < 5 cmA5b II: Confined to gland > 5 cmA5c III: Extraglandular extension without other organ involvementA5d IV: Distant metastasis or extension into other organs

Regional lymph nodes: A6x pNX: Cannot be assessedA6 pN0: No tumor noted in ___ nodesA7 pN1: Tumor present in ___ of ___ nodes

Distant metastasis: A10x pMX: Cannot be assessedA10 pM0: No distant metastasisA11 pM1: Present, involving: _____

Margin evaluation: A28x RX [presence of residual tumor cannot be assessed]A28 R0: Margins free of tumor. Distance of tumor from closest margin: ____ cm ( ____margin)

[Complete resection, no residual tumor left after resection]A28a R1: ____ margin involved by microscopic tumor

[Incomplete resection, margins involved by microscopic tumor]A28b R2: ____ margin involved by tumor [Incomplete resection; gross tumor at margin]

Vascular/Lymphatic vessel invasion: B30x IndeterminateB30 Not identifiedB30a Present

Additional findings: A13a None identifiedA13b [dictate list, example: Tumor necrosis; Hyperplasia; Adenoma; other ____]

Anus, Local Excision (Transanal disk excision) 41A14 Anal Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 6th Ed.)

Tumor configuration: A35a Exophytic (polypoid) A35c UlceratingA35b Infiltrative A35d Other (specify: ___________ )

Tumor size: A2 _____ x _____ x _____ cm

Histologic type: A17a Squamous cell carcinomaA17b Squamous cell carcinoma, large cell keratinizing typeA17c Squamous cell carcinoma, large cell nonkeratinizing typeA17d Squamous cell carcinoma, basaloid typeA17e Squamous cell Carcinoma in situ (Bowen’s disease)A17f AdenocarcinomaA17g Adenocarcinoma, rectal typeA17h Adenocarcinoma, of anal glandsA17i Adenocarcinoma, within anorectal fistulaA17j Adenocarcinoma, Paget’s diseaseA17k Small cell carcinomaA17l Giant condyloma (verrucous carcinoma)A17m Basal cell carcinomaA17n Undifferentiated, non-small cell carcinomaA17o [other]

Histologic grade: A18n Not applicable (if applicable to A18x GX: Cannot be assessed tumor type) A18a G1: Well differentiated

A18b G2: Moderately differentiatedA18c G3: Poorly differentiatedA18d G4: Undifferentiated

Extent of invasion: A20x pTX: [def.: Cannot be assessed]A20 pT0: [def.: No evidence of primary tumor]A20i pTis: [def.: Carcinoma in situ]A21 pT1: [def.: Tumor < 2 cm in greatest dimension]A22 pT2: [def.: Tumor > 2 cm but < 5 cm in greatest dimension]A23 pT3: [def.: Tumor > 5 cm in greatest dimension]A24 pT4: [def.: Tumor of any size with invasion of adjacent organ(s)] [ex., vagina,

urethra, bladder; note: involvement of sphincter muscles alone is not classified as pT4]

Regional lymph nodes: A6x pNX: Cannot be assessedA6 pN0: No tumor noted in ___ nodesA7 pN1: Tumor present in ___ of ___ nodes [def.: perirectal nodes]A8 pN2: Tumor present in ___ of ___ nodes

[def.: Metastasis in unilateral internal iliac and/or inguinal lymph node(s)]A9 pN3: Tumor present in ___ of ___ nodes

[def.: Metastasis in perirectal and inguinal lymph nodes and/or bilateral internal iliac and/or inguinal lymph nodes]





42Vascular/Lymphatic vessel invasion: B30x Indeterminate

B30 Not identifiedB30a Present

Perineural invasion: A29a Not identifiedA29b Present

Additional pathologic findings: A13a None identifiedA13b [dictate list, example: Crohn’s disease; condyloma accuminatum; dysplasia; associated rectal carcinoma (Paget’s disease); other ____ ]

A14a Neuroendocrine Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 7th Ed.) [Note: This is for gastro-intestinal carcinoid tumors. High-grade neuroendocrine

carcinomas and mixed glandular/well-differentiated NET’s are excluded and should be staged according to guidelines for staging carcinomas at that site.]

Tumor size: A2 _____ x _____ x _____ cmA2a Multifocal (__ tumor foci noted); largest focus measures ___ x ___ x ___ cm

Histologic type: A19a Well-differentiated neuroendocrine tumor [Note: see end comments]A19b Well-differentiated neuroendocrine carcinomaA19c [other; ex., Gangliocytic paraganglioma]

Histologic grade: A18n Not applicable (for GI NET’s) A18x GX: Cannot be assessed A18y G1 [< 2 mitoses/10 HPF; < 2% Ki-67] [evaluate 40 HPF for mit & 2000 Ki-67 stained cells]

A18z G2 [2-20 mitoses/10 HPF; 3-20% Ki-67]Note: G3 tumors have > 20 mitoses/10 HPF; >20 % Ki-67 – use the Carcinoma staging forms for G3 tumors

Extent of invasion: A20x pTX: [def.: Cannot be assessed]A20 pT0: [def.: No evidence of primary tumor]A20i pTis: [stomach: Carcinoma in situ/dysplasia (tumor size < 0.5 mm), confined to mucosa]A21 pT1: [stomach, small bowel: Tumor < 1 cm and invades lamina propria or submucosa]

[ampulla: Tumor > 1 cm]A21a pT1a: [appendix, colon, rectum: Tumor < 1 cm]A21b pT1b: [appendix, colon, rectum: Tumor 1-2 cm in size] A22 pT2: [stomach, small bowel: Tumor invades muscularis propria or > 1 cm in size]

[ampulla: Tumor > 1 cm] [appendix: >2 but < 4 cm or with extension to the cecum] [colon, rectum: Tumor invades muscularis propria or > 2 cm with invasion of lamina

propria or submucosa]A23 pT3: [stomach: Tumor penetrates subserosa]

[jejunum, ileum: Tumor invades through muscularis propria into subserosal tissue without penetration of overlying serosa, or into non-peritonealized tissues]

[ampulla, duodenum: Tumor invades pancreas or retroperitoneum, or into non-peritonealized tissues]

[appendix: > 4 cm or with extension to the ileum] [colon, rectum: Tumor invades through muscularis propria into subserosal tissue

without penetration of overlying serosa, or into non-peritonealized pericolonic or perirectal tissues]

A24 pT4: [stomach: Tumor invades visceral peritoneum (serosa) or other organs or adjacent structures]

[small bowel, ampulla, appendix, colon, rectum: invades peritoneum or other organs]




Regional lymph nodes: Distant metastasis:A6x pNX: Cannot be assessed A10x pMX: Cannot be assessedA6 pN0: No tumor noted in ___ nodes A10 pM0: No distant metastasisA7 pN1: Tumor present in ___ of ___ nodes A11 pM1: Present, involving: _____

Vascular/Lymphatic vessel invasion: Perineural invasion:B30x Indeterminate A29a Not identifiedB30 Not identified A29b PresentB30a Present

Additional pathologic findings: A13a None identifiedA13b [dictate list ]

Notes:Well-Differentiated Neuroendocrine Tumor

Benign: Nonfunctioning cytologically bland tumors confined to mucosa or submucosa,with no angioinvasion, and measuring not more than 1 cm in greatest dimension.

Uncertain malignant potential: Nonfunctioning cytologically bland tumors confined tomucosa or submucosa, with or without angioinvasion, or greater than 1 cm in size.

All gangliocytic paragangliomas without metastases are included in this category.

Well-differentiated Neuroendocrine CarcinomaLow-grade malignant potential: Nonfunctioning tumors that are larger than 2 cm or invade the muscularis

propria or beyond or are metastatic. All functional tumors,such as small gastrinomas, are included in this category

Foregut Tumors Midgut Tumors Hindgut TumorsSite Stomach, Proximal

DuodenumJejunum, Ileum,Appendix, ProximalColon

Distal Colon,Rectum

ImmunohistochemistryChromogranin ANeuron-Specific Enolase (NSE)SynaptophysinSerotonin

86%-100% +

90%-100% +50% +33% +

82%-92% +

95%-100% +95%-100% +86% +

40%-58% +

80%-87% +94%-100% +45%-83% +

OtherImmunohistochemicalMarkers

Rarely, + for pancreaticpolypeptide, histamine,gastrin, vasoactiveintestinal peptide (VIP),or adrenocorticotropichormone (ACTH)

Prostatic acidphosphatase + in20%-40%

Prostatic acidphosphatase + in20%-82%

Carcinoid Syndrome Rare 5%-39% Rare

Additional Pathologic FindingsPsammoma bodies are common in duodenal NE tumors,especially periampullary tumors14 expressing somatostatin and associated with vonRecklinghausen disease.

Mesenteric vascular changes (elastic vascular sclerosis) with midgut carcinoids may produce arterial luminal narrowing due to concentric adventitial accumulation of elastic tissue, & lead to intestinal ischemia and frank necrosis.

Histologic Grade: Cytologic atypia in low-grade neuroendocrine tumors has no impact on clinical behavior of these tumors. However, grading systems based on mitotic activity have been shown to have utility for foregut tumors. The following grading system is recommended:

Grade Mitotic Count (per 10 HPF) # Ki-67 Index (%)##G1 < 2 < 2G2 2 to 20 >2 to 20G3* >20 >20

# Mitotic count should be based upon counting 50 high-power (40x objective) fields in the area of highest mitotic activity and reported as number of mitoses per 10 HPF.

## Ki-67 index is reported as percentage of positive tumor cells in area of highest nuclear labeling. It has been recommended that 2000 tumor cells be counted to determine the Ki-67 index12; however, this practice may not be practical for routine clinical purposes, and it is acceptable to estimate the labeling index.

G1 and G2 are well-differentiated tumors with diffuse intense chromogranin/synaptophysin positivity. Punctate necrosis is more typical of G2 tumors.

*G3 tumors are high-grade neuroendocrine carcinomas (the CAP carcinoma checklist for the appropriate organ system should be used for poorly differentiated neuroendocrine carcinomas).

Gastric neuroendocrine tumors are divided into 4 types. (see table below)Type 1 tumors arising in the setting of atrophic gastritis with associated hypergastrinemia are the most

common. These lesions are composed of enterochromaffin-like (ECL) cells and are usually found as multiple small nodules in the body of the stomach and limited to mucosa and submucosa. Type 1 lesions are generally benign and

may regress following antrectomy; lymph node metastases are very rare and occur only when the tumors are large (greater than 2 cm) and infiltrate the muscularis propria.

Type 2 tumors are rare. These multifocal small tumors, which are associated with multiple endocrine neoplasia (MEN) type 1 with Zollinger-Ellison syndrome, develop in the body of the stomach, are usually smaller than 1.5 cm, and are confined to the mucosa or submucosa. However, in contrast to type 1 tumors, 30% metastasize. Tumors > 2 cm and invading the muscularis propria and exhibiting vascular invasion are more likely to metastasize.

Type 3 tumors, the second most common NE tumor in the stomach, are sporadic solitary tumors that are unassociated with atrophic gastritis or endocrine cell hyperplasia. These tumors may occur anywhere in the stomach. Metastasis is associated with larger mean size, angioinvasion, and invasion of muscularis propria. Surgical resection is usually advised for solitary gastric carcinoid tumors, particularly those larger than 2.0 cm, but tumors smaller than 1.0 cm have been rarely reported to metastasize.

Type 4 tumors are rare high-grade NE carcinomas that are usually bulky tumors with metastases at diagnosis (the CAP cancer checklist for gastric carcinoma applies). Gastric NE Tumors Type 1 Type 2 Type 3 Type 4Frequency 70%-80% of cases Rare 10%-15% of cases RareMultiplicity Multifocal Multifocal Solitary SolitarySize 0.5-1.0 cm ~1.5 cm or less Variable; one-third

are larger than 2 cmLarge

Location Corpus Corpus Anywhere in stomach Anywhere in stomachAssociations Hypergastrinemic

states; chronicatrophic gastritis,enterochromaffinlike(ECL) cell hyperplasia,pernicious anemia

Multipleendocrineneoplasia (MEN)type 1, withhypergastrinemiaor Zollinger-Ellison syndrome

Sporadic Sporadic

Clinical Behavior Usually benign 30% metastasize 71% of tumors>2 cm withmuscularis propriaand vascularinvasion havelymph nodemetastases

High-gradecarcinoma.Metastasescommon; poorprognosis

NE Tumor Size: throughout the GIT, size > 2.0 cm is associated with a higher risk of lymph node metastasis.

Stomach, types 3 and 4 NE tumors are significantly larger than type 1 tumors, which usually measure 1 cm or less (Table above). Tumor size correlates with depth of invasion for gastric NE tumors, with larger tumors more likely to be deeply infiltrative and at higher risk for metastases. Nodules measuring 0.5 mm or larger are defined as NE tumors; lesions measuring less than 0.5 mm are regarded as representing in situ tumor, NE cell dysplasia, or hyperplasia.

Most small bowel NE tumors occur in the distal ileum. Multiple tumors are found in 25-40% of cases. Metastatic risk is increased by tumor size >2 cm, involvement of the muscularis propria, and mitotic activity.

Appendiceal NE tumors smaller than 1.0 cm do not recur or metastasize. Those 1.0 to 2.0 cm rarely do. Tumor size >2.0 cm and mesoappendiceal invasion have been correlated with nodal metastasis, but not with poor outcome. For these reasons, appendectomy is sufficient for tumors 1.0 cm or smaller, as well as many tumors between 1.0 and 2.0 cm. More extensive procedures (eg, right hemicolectomy) are usually reserved for patients with tumors larger than 2.0 cm or with invasion beyond the muscularis propria.

Rectal NE tumors are common and constitute approximately ¼ of GI NE tumors. They are usually small, solitary, and clinically silent, most commonly occurring 4 to 13 cm from the anal verge. Mitotically inactive rectal NE tumors or those smaller than 2.0 cm are almost always clinically benign. Carcinoid syndrome is very rare. Large intestinal NE tumors outside the ileocecal region and rectum are extremely rare; most reported tumors have been large (average 5.0 cm) and high grade, with a poor prognosis. Many low-grade NE tumors involving the ileocecal valve represent tumors arising in the terminal ileum, rather than in the large bowel.

38A30 Ampulla of Vater Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 7th Ed.)

Tumor site: A31a Intra-ampullary A31b Peri-ampullaryA31c Junction of ampullary and duodenal mucosa

Tumor size: A2 _____ x _____ x _____ cm

Histologic type: A32a Carcinoma in situA32b Papillary adenocarcinomaA32c Adenocarcinoma, intestinal typeA32d Adenosquamous carcinomaA32e Mucinous adenocarcinomaA32f Clear cell adenocarcinomaA32g Signet-ring cell adenocarcinoma [G3 tumor]A32h Small cell carcinoma [G4 tumor]A32i Other: __[squamous cell ca, large cell NE ca, etc.]

Histologic grade: A18x GX: Cannot be assessedA18a G1: Well differentiated ( > 95% gland forming)

[this grading system A18b G2: Moderately differentiated ( 50-95 % gland forming)is for non-papillary A18c G3: Poorly differentiated (5-49 % gland forming)adenocarcinoma] A18d G4: Undifferentiated ( < 5 % gland forming)

Extent of invasion: A20x pTX [def.: Cannot be assessed]A20 pT0 [def.: No evidence of primary tumor]A20i pTis [def.: Carcinoma in situ]A21 pT1 [def.: Tumor limited to ampulla of Vater or sphincter of Oddi]A22 pT2 [def.: Tumor invades duodenal wall]A23 pT3 [def.: Tumor invades pancreas]A24 pT4 [def: Tumor invades peripancreatic soft tissues and/or other adjacent structures/organs]






Margins for review include:



Additional pathologic findings:A13a None identifiedA13b Additional pathologic findings: [dictate list, ex.: dysplasia/adenoma; ampullitis; adenomyosis;

chronic or acute pancreatitis; other]

Breast, lumpectomy or mastectomy 1B1 Breast Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 7th Ed.)

Tumor size: B2 _____ x _____ x _____ cm

Tumor site: B3a Right breast, upper outer quadrant B3e Left breast, upper outer quadrantB3b Right breast, lower outer quadrant B3f Left breast, lower outer quadrantB3c Right breast, upper inner quadrant B3g Left breast, upper inner quadrantB3d Right breast, lower inner quadrant B3h Left breast, lower inner quadrant

Histologic type:B4a Cannot be determined B4n Invasive secretory (juvenile) carcinomaB4b Noninvasive carcinoma (NOS) B4p Invasive apocrine carcinomaB4c Ductal carcinoma in situ B4q Invasive cribriform carcinomaB4e Lobular carcinoma in situ B4r Invasive ductal carcinoma with Paget’s diseaseB4f Invasive ductal carcinoma B4s Paget’s disease of the nipple,B4g Invasive ductal carcinoma with an without invasive carcinoma

extensive intraductal component B4t Carcinoma with squamous metaplasiaB4h Invasive lobular carcinoma B4x Carcinoma with metaplasia, mixed type B4i Invasive mucinous carcinoma B4u Carcinoma with spindle cell metaplasiaB4j Invasive medullary carcinoma B4w Carcinoma with cartilaginous and osseousB4k Invasive papillary carcinoma metaplasiaB4L Invasive tubular carcinoma B4y Inflammatory carcinomaB4m Invasive adenoid cystic carcinoma B4z Other(s) [specify: _______ ]

Histologic grade, Nottingham system: B5a Cannot be determinedB5b Grade I [3 – 5 points]B5c Grade II [6 – 7 points]B5d Grade III [8 – 9 points]

Tubule Formation: B6a Majority of tumor , > 75% [score = 1]B6b Moderate, 10% to 75% [score = 2]B6c Minimal, <10% [score = 3]

Nuclear grade: B7a I [Small regular nuclei; score = 1]B7b II [Moderate increase in size, etc.; score = 2]B7c III [Marked variation in size, nucleoli, chromatin, etc; score= 3]

Mitotic count: B8a low mitotic activity [< 7 mitoses per 10 HPF; score = 1]B8b moderate mitotic activity [8 – 15 mitoses per 10 HPF; score = 2]B8c high mitotic activity [>16 mitoses per 10 HPF; score = 3]




Lumpectomy margins, distance from lesional tissue: [BRH]B10a Anterior margin -- ____ cm B10e Medial margin -- ____ cmB10b Posterior margin -- ____ cm B10f Lateral margin -- ____ cmB10c Superior margin -- ____ cm B10g [Other] margin -- ____ cmB10d Inferior margin -- ____ cm

2

Extent of invasion: B11 pTX: Cannot be determined

B12 pT0 [No evidence of primary tumor]

B13 pTis [Carcinoma in situ; ex., DCIS, LCIS, Paget’s disease of the nipple w/ no tumor]B13a pTis (DCIS) Ductal carcinoma in situB13b pTis (LCIS) Lobular carcinoma in situB13c pTis (Paget’s) Paget’s disease of the nipple with no invasive tumor [Note: Paget’s

disease with a tumor is classified according to the size of the invasive tumor]

B14 pT1 [Tumor < 2 cm in greatest dimension]B14m pT1mic [Microinvasive tumor < 0.1 cm in greatest dimension]B14a pT1a [Tumor > 0.1 cm but < 0.5 cm in greatest dimension]B14b pT1b [Tumor > 0.5 cm but < 1 cm in greatest dimension]B14c pT1c [Tumor > 1 cm but < 2 cm in greatest dimension]

B15 pT2 [Tumor > 2 cm but < 5 cm in greatest dimension]

B16 pT3 [Tumor > 5 cm in greatest dimension]

B17 pT4 [Tumor of any size with direct extension to chest wall or skin*]B17a pT4a [Extension to chest wall, not including pectoralis muscle]B17b pT4b [Edema (incl. Peau d’orange) or ulceration of the skin of the breast or

satellite skin nodules confined to the same breast]B17c pT4c [Both pT4a and pT4b]B17d pT4d [Inflammatory carcinoma]

* Note with respect to skin involvement: Dermal invasion alone does not alter T category. To be called ‘skin involvement’ you need ulceration, satellite nodules, or inflammatory breast cancer. Cases with only dermal involvement are classified as T1, T2, or T3, depending on tumor size.

Regional lymph nodes: [Note: Classification is based on axillary lymph node dissection with or without sentinel lymphnode dissection. Classification based SOLELY on SENTINEL LYMPH NODES without subsequent axillary lymph node dissection is designated (sn) --> eg. pN0(i+) (sn).]

B18x pNX: Cannot be assessed [def.: cannot be assessed -- previously removed or not removed]

B18 pN0: No tumor noted in __ lymph nodes [def.: No regional lymph node metastasis; no immunos done]

B19 pN0(i-): No tumor, including isolated tumor cells, noted in __ lymph nodes by H&E stain or immunohistochemistry

B19s pN0(i-) (sn): No tumor, including isolated tumor cells, noted in __ sentinel lymph nodes H&E stain or immunohistochemistry

B20 pN0(i+): Only isolated tumor cells (ITCs) noted in __ of __ lymph nodes by H&E stain or immunohistochemistry; no ITC cluster > 0.2 mm

B20s pN0(i+) (sn): Only isolated tumor cells (ITCs) tumor noted in __ of __ sentinel lymph nodes by H&E stainor immunohistochemistry, no ITC cluster > 0.2 mm.

B19m pN0(mol-): No tumor noted in __ lymph nodes by H&E stain, negative molecular findings (RT-PCR) B19ms pN0(mol-) (sn): No tumor noted in __ sentinel lymph nodes by H&E stain, negative molecular

findings (RT-PCR) B20m pN0(mol+): No tumor noted in __ lymph nodes by H&E stain, positive molecular findings (RT-PCR) B20ms pN0(mol+) (sn): No tumor noted in __ sentinel lymph nodes by H&E stain, positive molecular

findings (RT-PCR)

B21 pN1: Tumor present in __ of __ lymph nodes 3[def.: Mets: in 1 to 3 movable axillary nodes

OR, in 1 to 3 internal mammary sentinel nodes which are “not clinically apparent”(ie., undetected by imaging studies or by clinical examination)]

B21m pN1mi: Micrometastasis present in __ of __ lymph nodes [def.: micromet > 0.2 mm and < 2.0 mm] B21ms pN1mi (sn): Micrometastasis present in __ of __ sentinel lymph nodes [def.: micromet > 0.2mm & < 2 mm] B21a pN1a: Tumor present in __ of __ axillary lymph nodes

[def: Mets in 1to 3 axillary nodes; at least one of which is > 2 mm] B21as pN1a (sn): Tumor present in __ of __ axillary sentinel lymph nodes

[def: Mets in 1to 3 axillary sentinel nodes (no axillary dissection ), at least one of which > 2 mm] B21b pN1b: Tumor present in __ of __ internal mammary lymph nodes

[def: Mets in 1 to 3 clinically inapparent internal mammary sentinel nodes] B21c pN1c: Tumor present in __ of __ axillary lymph nodes and in __ of __ internal mammary lymph nodes

[def: Mets in 1 to 3 axillary nodes and in internal mammary nodes; use pN3b if > 3 axillary nodes]____

B22 pN2: Tumor present in __ of __ lymph nodes[def.: Mets: in 4 to 9 axillary nodes,

OR, in internal mammary nodes which are “clinically apparent” in the absence of axillary node mets]

B22a pN2a:Tumor present in __ of __ axillary lymph nodes[def: Mets in 4 to 9 axillary nodes; at least one > 2 mm]

B22b pN2b: Tumor present in __ of __ internal mammary lymph nodes[def: “clinically apparent” internal mammary nodes in the absence of axillary mets]

____B23 pN3 Tumor present in __ of __ lymph nodes

[def. Mets: in > 10 axillary nodes,OR, in infraclavicular nodes, OR, in “clinically apparent” internal mammary nodes in the presence of

> 1 positive axillary lymph nodes,OR, in > 3 axillary nodes and microscopic mets in internal mammary nodes

which are “not clinically apparent”,OR, in supraclavicular lymph nodes.]

B23a pN3a: Tumor present in __ of __ lymph nodes [def: Mets: in > 10 axillary nodes,

OR, in infraclavicular lymph nodes.] B23b pN3b: Tumor present in __ of __ lymph nodes

[def: Mets: in “clinically apparent”internal mammary nodes in the presence of> 1 positive axillary lymph nodes,

OR, in > 3 axillary nodes and microscopic mets in internal mammary nodeswhich are “not clinically apparent”.]

B23c pN3c: Tumor present in __of__ipsilateral supraclavicular lymph nodes

Size of largest nodal metastasis: B27 ___ cm

Extranodal tumor extension:B28a NoB28b Yes

Vascular/Lymphatic vessel invasion:B30x IndeterminateB30 Not identifiedB30a Present

Distant metastasis:A10x pMX: Cannot be assessedA10 pM0: No distant metastasisA11 pM1: Present, involving: _____

Nipple involvement:B32a AbsentB32b Present

Additional findings:A13a None identifiedA13b [dictate list, ex.: Microcalcification,

fibrocystic changes, atypical hyperplasia]

Receptor studies: B33a Receptor assay panel pending B33b Previously performed on case xS1x - xxxx:

ER __%; PR __%; Her2neu __; Ki-67__%.

4 Colon or Rectum, resectionC1 Colon Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 7th Ed.)C2 Rectal Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 7th Ed.)

Specimen type: C2b: Right hemicolectomy C2f: Rectal/rectosigmoid colon (low anterior resection)C2c: Transverse colectomy C2g: Total abdominal colectomyC2d: Left hemicolectomy C2h: Abdominoperineal resectionC2e: Sigmoidectomy C2i: Other (specify): ________

C2k: Not specifiedTumor size: A2 _____ x _____ x _____ cm

Tumor site: C2a ______ (identify from following: Cecum // Right (ascending) colon // Hepatic flexure //Transverse colon // Splenic flexure // Left (descending) colon // Sigmoid colon //Rectosigmoid colon // Rectum // Colon, not otherwise specified

Macroscopic intactness of mesorectum: [RECTAL Cases Only; The entire specimen is scored according to the worst area.]C7a Cannot be determinedC7b Incomplete [little bulk to mesorectum; defects down to musc. propria; very irregular radial

margin on examination of transverse sections]C7c Nearly complete [moderate bulk; irregularity to mesorectal radial surface, with defects > 5mm but

none extending to musc. propria; musc. propria not visible except at insertion site of levator ani muscles]

C7d Complete [intact bulky mesorectum with only minor defects to radial surface (< 5 mm); no coning toward distal margin of resection; smooth margin on transverse sxns]

Perforation: C2p No perforation notedC2q Perforation of tumor involved colon wall presentC2r Non-tumor perforation of colon wall present

Histologic type: C3a Adenocarcinoma in situ / severe dysplasiaC3b AdenocarcinomaC3c Mucinous adenocarcinoma, estimated percentage: __% [must be >50% mucinous]C3d Signet ring cell carcinoma, estimated percentage: __% [must be >50% signet ring cells]C3e Undifferentiated carcinomaC3f [other; specify ex., Medullary carcinoma; Small cell carcinoma; Large cell neuroend. ca]

Histologic grade: A18e Not applicableA18f Cannot be assessedA18p Low-grade (well to moderately differentiated) [ > 50% gland forming ]A18r High-grade (poorly differentiated to undifferentiated) [ < 50% gland forming; signet-ring cell or

high grade neuroendocrine (small cell) ]

Extent of invasion: A20x pTX [Cannot be assessed]A20 pT0 [No evidence of primary tumor]A20i pTis [Carcinoma in situ, intraepithelial (no invasion: AKA high grade dysplasia)]A21 pT1 [Tumor invades submucosa]A22 pT2 [Tumor invades muscularis propria]A23 pT3 [Invasion through musc. prop. into subserosa or pericolic or perirectal soft tissues]A24a pT4a [Tumor penetrates the visceral peritoneum: either as serosal involvement by tumor with

inflammatory reaction, mesothelial hyperplasia, and/or erosion/ulceration; or, free tumor cells on serosal surface with underlying ulceration of visceral peritoneum ]

A24b pT4b [Tumor directly invades or is adherent to other organs or structures; note: if no tumor is found within the adhesion microscopically, the tumor should be assigned pT3.]

Note: For rectal tumors, invasion of the external sphincter is classified as pT3, whereas invasion of the levator ani muscle(s) is pT4.

Regional lymph nodes:B18x pNX: Cannot be assessed [def.: cannot be assessed -- previously removed or not removed]B18 pN0: No tumor noted in __ lymph nodes [def.: No regional lymph node metastasis; no immunos done]B19 pN0(i-): No tumor, including isolated tumor cells, noted in __ lymph nodes by H&E stain or Immuno-his.ch.B20 pN0(i+): Only isolated tumor cells (ITCs) noted in __ of __ lymph nodes by H&E stain or

immunohistochemistry; no ITC cluster > 0.2 mmB21 pN1: Tumor present in __ of __ lymph nodes [1 to 3 nodes +]B21m pN1(mic): Micrometastasis present in __ of __ lymph nodes [def.: micromet > 0.2 mm and < 2.0 mm] B21x pN1a: Tumor present in 1 of __ lymph nodesB21y pN1b: Tumor present in __ [2 to 3] of __ lymph nodesB21z pN1c: Tumor deposit(s) in the subserosa, or non-peritonealized pericolic or perirectal tissues

without regional lymph node metastasis [see Tumor Deposit note below]B22 pN2: Tumor present in __ of __ lymph nodes [4 or more +]B22x pN2a: Tumor present in __ [4 to 6] of __ lymph nodesB22y pN2b: Tumor present in __ [7 or more] of __ lymph nodes

Lymph Nodes note: All grossly negative or equivocal lymph nodes are to be submitted entirely. Grossly positive lymph nodes may be partially submitted for microscopic confirmation of metastasis. Removal and pathologic examination of at least 12 lymph nodes from resected colon cancer cases is desired.

If applicable, add: Size of largest nodal metastasis: B27 ____ cm

Extranodal tumor extension: B28a NoB28b Yes

Tumor deposits (discontinuous extramural extension): [see note below]B34a IndeterminateB34b AbsentB34c ___ tumor deposits noted

Tumor Deposit note: A tumor nodule in the pericolonic/perirectal fat without histologic evidence of residual lymph node tissue is no longer classified in the N category as regional nodal metastasis (i.e., lymph node replacement by tumor). It is now classified as a tumor deposit (pertumoral deposit or satellite nodule). Such tumor deposits may represent discontinuous spread, lymph-vascular spread with extravascular extension, perineural invasion (rarely), or totally replaced lymph nodes. Such nodules are recorded in the “Tumor Deposit” macro (see below). Also, in the absence of unequivocal lymph node metastases, tumor deposits are recorded as N1c. Also, in cases otherwise classified as pT1 or pT2, the presence of ‘tumor deposits’ does not change the pT classification.

Margin evaluation: (includes proximal, distal and radial/mesenteric [ie., nonperitonealized] margin)A28x RX [presence of residual tumor cannot be assessed]A28 R0: Margins free of tumor. Distance of tumor from closest margin: ____ cm ( ____margin)

[Complete resection, no residual tumor left after resection. Note: the radial or mesenteric margin isconsidered negative if tumor is > 1 mm from the inked nonperitoneal covered rectal or mesenteric surface, and positive if tumor is 0-1mm from this surface. This assessment includes tumor within a lymph node aswell as direct tumor extension, but if radial margin positivity is based solely on intranodal tumor, this should be so stated.]

A28a R1: ____ margin involved by microscopic tumor [Incomplete resection, margins involved by microscopic tumor]A28b R2: ____ margin involved by tumor [Incomplete resection; gross tumor at margin]

Distant metastasis: A10x pMX: Cannot be assessedA10 pM0: No distant metastasisA11 pM1: Present, involving: _____ A11a pM1a: Present, involving: ___ [for metastasis to a single organ or site (eg, liver, lung,

ovary, nonregional lymph node)] A11b pM1b: Present, involving: ___ [for metastasis to more than one single organ or site]



Peritoneal involvement by tumor: C5a No C5b Yes

Treatment effect: [for carcinomas treated with neoadjuvant therapy: see note below] C8a Grade 0: Complete response; no residual tumor noted.C8b Grade 1: Moderate response; minimal residual tumor noted.C8c Grade 2: Minimal response.C8d Grade 3: No definite response identified.

Additional pathologic findings: A13a None identifiedA13b [dictate list, ex.: Crohn’s disease; UC; dysplasia; polyps; other ____ ]

Notes:A tumor is classified as rectal if its inferior margin lies less than 16 cm from the anal verge or if any part of the tumor is located at least partly within the supply of the superior rectal artery. A tumor is classified as rectosigmoid when differentiation between rectum and sigmoid according to the previously mentioned guidelines is not possible.

Serrated PolypsDistinction should be made between traditional serrated adenomas, which exhibit cytologic features of adenomas, and the newly described sessile serrated adenomas. The sessile serrated adenoma may be the precursor lesion for colorectal carcinomas with high levels of microsatellite instability (MSI-H); they are more commonly found in the right colon and are characterized by serrated architecture with bulbous dilatation of deep crypts and lack of overt nuclear atypia, in most cases.

Histologic type - Medullary carcinoma is a distinctive histologic type (solid growth in nested, organoid, or trabecular patterns, with no immunohistochemical evidence of neuroendocrine differentiation; usually with numerous tumor infiltrating lymphocytes) strongly associated with high levels of microsatellite instability (MSI-H), indicative of defects in normal DNA repair gene function. Medullary carcinoma may occur either sporadically8 or in association with hereditary nonpolyposis colon cancer (HNPCC).

pTNM Descriptors (required only if applicable; select all that apply) Although they do not affect the stage grouping, they indicate cases needing separate analysis.

“m” suffix : pT(m)NM - indicates the presence of multiple primary tumors in a single site and is recorded in parentheses.“y” prefix : ypTNM - indicates cases performed during or following initial neoadjuvant chemotherapy, radiation therapy,

or both. The designation categorizes the extent of tumor present at the time of that examination and is not an estimate of tumor prior to neoadjuvant therapy.

“r” prefix : rTNM - indicates recurrent tumor staged after a documented disease-free interval.

Treatment Effect – Neoadjuvant chemoradiation therapy in rectal cancer is associated with significant tumor response and downstaging. Tumor regression should be assessed only in the primary tumor; lymph node metastases should not be included in the assessment. Acellular pools of mucin in specimens from patient receiving neoadjuvant therapy are considered to represent completely eradicated tumor and are not used to assign pT stage or counted as positive lymph nodes.

Tumor Regression Grade (modified from Ryan et al)Description Tumor Regression Grade

No viable cancer cells 0 (Complete response)

Single cells or small groups of cancer cells 1 (Moderate response)

Residual cancer outgrown by fibrosis 2 (Minimal response)

Minimal or no tumor kill; extensive residual cancer 3 (Poor response)

Microsatellite Instability Testing: recommended for any of the following circumstances:1. Pt < 50 yo2. Presence of synchronous, metachronous or other HNPCC (Lynch syndrome)-associated tumors – endometrial, stomach,

ovarian, pancreas, ureter and renal pelvis, biliary tract, small bowel, brain tumor, sebaceous adenomas and KA’s.3. Pt < 60 yo with MSI-H histology:

a. tumor infiltrating lymphocytes (3 or more per high-power [x400] field)b. Crohn-like peritumoral lymphocytic response (non-lymph node aggregates or follicles at the tumor edge)c. Mucinous or signet-ring cell differentiationd. Medullary growth patterne. High histologic grade (right-sided location and lack of dirty necrosis are also associated with MSI-H status)

4. Pt with 1 or more 1st degree relatives with an HNPCC-related tumor, one of which was diagnosed while under 50 yo5. Pt with 2 or more 1st or 2nd degree relatives with HNPCC-related tumors regardless of age

Endometrium, hysterectomy 15F20 Endometrial Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 7th Ed.)Tumor size: A2 ____ x ____ x ____ cmHistologic type: [see Notes below]

F21a Endometrioid adenocarcinoma F21i Transitional cell carcinomaF21b Endometrioid adenocarcinoma, secretory var. F21j Squamous cell carcinomaF21c Endometrioid adenocarcinoma, ciliated cell var. F21k Mixed carcinoma [when two or moreF21d Endometrioid adenocarcinoma, w/ squamous diff. subtypes of endometrial CA are present,F21e Endometrioid adenocarcinoma, villoglandular var. each representing more >10% of tumorF21f Mucinous adenocarcinoma F21m Carcinosarcoma F21g Serous adenocarcinoma F21p Undifferentiated carcinomaF21h Clear cell adenocarcinoma F21q Other, specify: _______( ex. Small cell ca)

Histologic grade: F22 Not applicableF22x GX: Cannot be accessed

For endometrioid and mucinous carcinoma only: [see Notes below on raising grade due to nuclear atypia]F22a FIGO grade 1 [ < 5 % non-squamous solid growth]F22b FIGO grade 2 [6 – 50 % non-squamous solid growth]F22c FIGO grade 3 [> 50 % non-squamous solid growth]

For other carcinomas:A18a G1: Well differentiatedA18b G2: Moderately differentiatedA18c G3: Poorly differentiatedA18d G4: Undifferentiated

TNM (FIGO): F9x pTX (--): Cannot be assessed

F9 pT0 (--) [No evidence of primary tumor]F9i pTis (--) [Carcinoma in situ]F11 pT1 (I) [Tumor confined to corpus uteri]

Note: if tumor also F11a pT1a (IA) [Tumor limited to endometrium or invades < ½ of myometrium] has a metastasis, F11b pT1b (IB) [Tumor invades one half or more of myometrium] change the FIGO F12 pT2 (II) [Tumor invades stromal connective tissue of the cervix (not just epithelium)] stage to IVB, F13 pT3 (III) Local and/or regional spread as specified below; whatever the TNM F13a pT3a (IIIA) [Tumor involves serosa and/or adnexa (direct extension or metast.)]

stage is. F13b pT3b (IIIB) [Vaginal involvement (direct extension or metastasis)] or parametrial involv.]

F14 pT4 (IVA) [Tumor invades mucosa of bladder or bowel mucosa]

Myometrial invasion: F23x Not identified [see Notes below] F23 Present: Depth of invasion __ mm; Myometrial thickness __ mm

Regional lymph nodes: A6x pNX: Cannot be assessedA6 pN0: No tumor noted in ___ nodesA9d pN1 (FIGO IIIC1): Tumor present in ___ of ___ pelvic lymph nodes

if (+) para-aortic l.n. A9e pN2 (FIGO IIIC2): Tumor present in __ of __ nodes, including __ para-aortic lymph nodes

Distant metastasis: A10x pMX: Cannot be assessedA10 pM0: No distant metastasisF14b pM1 (FIGO IVB): Present, involving: ______

Margin evaluation: A28x RX [presence of residual tumor cannot be assessed] [see Notes below] A28 R0: Margins free of tumor. Distance of tumor from closest margin: ____ cm ( ____margin)




Additional pathologic findings: A13a None identified

A13b [dictate list, example: simple and/or complex hyperplasia, with or without atypia]

Notes:Histologic type: a. High-grade tumors with ambiguous features should be classified as “carcinoma, subtype cannot be determined”; however, this is a very infrequent situation and every effort should be made to subclassify such tumors. b. Serous carcinomas may display a glandular architecture. When a gland-forming endometrial carcinoma shows high-grade nuclear features, the diagnosis of serous carcinoma should be considered. c. Carcinosarcoma (also referred to as malignant müllerian mixed tumor [MMMT]) is a high-grade endometrial neoplasm that is staged like endometrial carcinomas because it is thought to represent a high-grade metaplastic carcinoma. Dx requires presence of both a malignant epithelial component and a malignant sarcomatous component in the neoplasm, which should not merge.

Proposed Criteria Defining Endometrial Carcinoma versus Endometrial Hyperplasia(1) Irregular infiltration of glands associated with an altered fibroblastic stroma (desmoplastic response), or(2) Confluent glandular pattern (cribriform growth) [defined by Kurman and Norris to be at least 1.9 mm in diameter], or(3) Extensive papillary growth pattern [defined in one study to be at least 4.2 mm in diameter], or(4) Severe cytologic atypia (G3 nuclear atypia)

Histologic grade: a. Severe nuclear atypia (grade 3 nuclei) raises a grade 1 tumor to grade 2, or an otherwise grade 2 tumor to grade 3. b. The squamous component of endometrioid adenoca. should not be graded (usually it parallels the glandular component).c. Mucinous carcinomas are closely related to endometrioid carcinomas and can be graded by the same criteria.d. Serous, clear cell, transitional, small cell,undifferentiated carcinomas, and carcinosarcomas are generally considered to

be high grade and it is not recommended to assign a FIGO grade to these tumor types. Designate them “not applicable.”e. In mixed carcinomas, the highest grade should be assigned.

Myometrial Invasion Carcinoma involving adenomyotic foci should not be interpreted as invasive carcinoma. However, the distinction between invasive carcinoma and carcinoma involving adenomyosis may be difficult, because in some cases invasive carcinoma may not elicit stromal response. In the absence of adenomyosis uninvolved by tumor in other sections of the specimen, a diagnosis of adenomyosis involved by adenocarcinoma should be made with caution. There are no rules for determining how to measure the depth of invasion in the rare cases where myoinvasive carcinoma is only encountered in foci of adenomyosis involved by carcinoma. In such cases, it is advised that the distance from the adenomyotic focus to the deepest area of invasion be measured (Figure 1).13 Therefore, if there is a tumor with a 2-mm focus of myoinvasion from a focus of adenomyosis in the deep myometrium, it is still considered as having <50% myometrial invasion (FIGO stage IB).

Margins: The paracervical soft tissue is the only true margin in total hysterectomy specimens, and reporting the status of this margin is usually not performed; conversely, reporting the status of the vaginal and parametrial margins in a radical hysterectomy specimen isoptional.

Cervical Involvement: Cervical involvement by endometrial carcinoma has been traditionally divided into 2A when there was only secondary involvement of the endocervical epithelium and 2B when the endometrial carcinoma invaded the cervical stroma. Recently, it has been shown that involvement of the surface endocervical epithelium and/or endocervical glands (either by direct extension or drop metastases) does not have any prognostic significance. Therefore, the new American Joint Committee on Cancer (AJCC)/FIGOstaging system considers stage II disease only when cervical stromal involvement is seen.

16If other organs are attached, specify whether tumor is present or not. If present, specify whether by direct extension or metastasis. If an independent tumor is present use the appropriate Staging Form.

E58 Other organs:Vagina: E18 Not applicable

E19 No tumor presentE20 Tumor present by direct extensionE21 Tumor present by metastasisE22 Independent primary tumor present (see Vagina Staging Information)

Vulva: E23 Not applicableE24 No tumor presentE25 Tumor present by direct extensionE26 Tumor present by metastasisE27 Independent primary tumor present (see Vulva Staging Information)

Right fallopian tube: E28 Not applicableE29 No tumor presentE30 Tumor present by direct extensionE31 Tumor present by metastasisE32 Independent primary tumor present (see Fallopian Tube Staging Information)

Left fallopian tube: E33 Not applicableE34 No tumor presentE35 Tumor present by direct extensionE36 Tumor present by metastasisE37 Independent primary tumor present (see Fallopian Tube Staging Information)

Right ovary: E38 Not applicableE39 No tumor presentE40 Tumor present by direct extensionE41 Tumor present by metastasisE42 Independent primary tumor present (see Ovary Staging Information)

Left ovary: E43 Not applicableE44 No tumor presentE45 Tumor present by direct extensionE46 Tumor present by metastasisE47 Independent primary tumor present (see Ovary Staging Information)

Bladder: E48 Not applicableE49 No tumor presentE50 Tumor present by direct extensionE51 Tumor present by metastasisE52 Independent primary tumor present (see Urinary Bladder Staging Information)

Rectum: E53 Not applicableE54 No tumor presentE55 Tumor present by direct extensionE56 Tumor present by metastasisE57 Independent primary tumor present (see Colon / Rectum Staging Information)

[Other organs: specify _____] Then dictate one of the following:Not applicableNo tumor presentTumor present by direct extensionTumor present by metastasisIndependent primary tumor present (see [appropriate] Staging Information)

Esophagus, resection 31E1 Esophagus Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 7th Ed.)

Tumor Size: A2 ____ x ____ x ____ cm [Note: The pathologist should record in the gross:1. The maximum longitudinal dimension of the tumor mass, 2. The distance of the tumor midpoint from the EGJ, and 3. The relative proportions of the tumor mass located in the

esophagus and in the stomach.]Tumor Site: C2a __ [ex.: Proximal es.; Midesophagus; Distal es.; Esophagogastric junction (EGJ); Proximal stomach and EGJ]

Histologic type: E2a Squamous cell carcinoma[add Verrucous type or Spindle type, as appropriate]

E2b AdenocarcinomaE2c Adenosquamous carcinoma

E2d Mucoepidermoid carcinomaE2e Adenoid cystic carcinomaE2f Small cell carcinomaE2g Undifferentiated carcinomaE2h Other: specify_________

Note: types E2d through E2g are not generally graded (next section)

Histologic grade: A18x GX: Cannot be assessedA18a G1: Well differentiated [if an adenocarcinoma, use ‘>95% composed of glands]A18b G2: Moderately differentiated [if an adenocarcinoma, use 50-95% composed of glands]A18c G3: Poorly differentiated [if an adenocarcinoma, use <50% composed of glands]A18d G4: Undifferentiated

Extent of invasion: A20x pTX [Cannot be assessed]A20 pT0 [No evidence of primary tumor]A20i pTis [High grade dysplasia]A21 pT1 [Tumor invades lamina propria, muscularis mucosae, or submucosa]A21a pT1a [Tumor invades lamina propria or muscularis mucosae]A21b pT1b [Tumor invades submucosa]A22 pT2 [Tumor invades muscularis propria; Note: the muscularis mucosae is commonly

duplicated and thickened in Barrett’s esophagus; invasion of this layer should not be misinterpreted as invasion of muscularis propria]

A23 pT3 [Tumor invades adventitia]A24 pT4 [Tumor invades adjacent structures: specify ___]A24a pT4a Tumor invades: ___ [Resectable tumor invading pleura, pericardium or diaphragmA24b pT4b Tumor invades: ___ [Unresectable tumor invading structures such as aorta, vertebral

bodies, trachea, etc.]

Regional lymph nodes: A6x pNX: Cannot be assessedA6 pN0: No tumor noted in ____ nodesA7 pN1: Tumor present in ___ of ___ nodes [mets in 1 to 2 nodes]A8 pN2: Tumor present in ___ of ___ nodes [mets in 3 to 6 nodes]A9 pN3: Tumor present in ___ of ___ nodes [mets in 7 or more nodes]






Additional findings: A13a None identifiedA13b [dictate list, example: Intestinal metaplasia; dysplasia; esophagitis (type: ___ ); gastritis; other]

Notes:Location: This protocol applies to all carcinomas arising in the esophagus and to carcinomas that are predominantly in the proximal stomach but which cross the esophago-gastric junction (EGJ). The EGJ is defined as the junction of the tubular esophagus and the stomach, irrespective of the type of epithelial lining of the esophagus.

Tumors involving the EGJ are classified for purposes of staging as esophageal carcinomas. The World Health Organization (WHO) defines esophageal tumors are those located entirely above the EGJ and proximal gastric tumors as those located entirely below the EGJ. Tumors crossing the EGJ are classified as EGJ tumors.

E6 Perihilar Bile Duct Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 7th Ed.) [Note: This is for tumors arising from the hepatic duct bifurcation to the origin of the cystic duct. For tumors of the cystic duct, use the gallbladder staging form.]

Tumor Size: A2 ____ x ____ x ____ cmTumor Site: ___ [select all that apply from the following: Right

hepatic duct; Left hep. duct; Junction of right and left hep. ducts; Cystic duct (tumors arising in the C.D.--> use the GB form); Common hepatic duct; Common bile duct]

Histologic type: E7a Carcinoma in situ E7b Adenocarcinoma, NOSE7d Clear cell adenocarcinomaE7e Mucinous carcinomaE7f Signet ring cell carcinoma E7g Squamous cell carcinomaE7h Adenosquamous carcinomaE7i Papillary carcinoma E7j Small cell carcinomaE7p Biliary cystadenocarcinomaE7k Undifferentiated carcinoma

[distinguish spindle and giant cell types]E7m Other: ______ [Note: Sarcomas and Carcinoids are Not included w/ this TNM staging]

Histologic grade: A18x GX: Cannot be assessed

>95% glands A18a G1: Well differentiated50-95% glands A18b G2: Moderately differentiated<50% glands A18c G3: Poorly differentiated

A18d G4: Undifferentiated

Extent of invasion: A20x pTX: Cannot be assessedA20 pT0 [No evidence of primary tumor]A20i pTis [Carcinoma in situ; Epithelium only; includes non-invasive ca with a papillary pattern]A21 pT1 [Tumor confined to the bile duct, with extension up to the muscle layer or fibrous tissue]A22a pT2a [Tumor invades beyond the bile duct wall into surrounding adipose tissue]A22b pT2b [Tumor invades adjacent hepatic parenchyma]A23 pT3 [Tumor invades unilateral branches of the portal vein or hepatic artery]A24 pT4 [Tumor invades: main portal vein (p.v.) or its branches bilaterally; or the common hepatic

artery (h.a.); or the 2nd -order biliary radicals bilaterally; or unilateral 2nd -order biliary radicals along with contralateral p.v. or h.a.]

Regional lymph nodes: A6x pNX: Cannot be assessedA6 pN0: No tumor noted in ___ nodes [fill in the blank with the number of nodes]A7 pN1: Tumor present in __ of __ nodes [along cystic duct, common b.d., hep. art & portal v.]A8 pN2: Tumor present in __ of__ nodes [periaortic, pericaval, sup.mesenteric art, celiac art.nodes]

Distant metastasis: A10x pMX: Cannot be assessed [Note: bile duct ca is often multifocal. 5% of bile duct ca A10 pM0: No distant metastasis pts have gallbladder ca; examine and section thoroughly]A11 pM1: Present, involving: _____




Note: Margin examination for R0, R1 and R2 include: proximal bile duct, distal bile duct, and radial margins


Perineural invasion: A29a Not identified [Caution: perineural invasion by benign hyperplastic intramural glands has A29b Present beenreported in primary sclerosing cholangitis & adenomatous hyperplasia.]

Additional findings: A13b [if present, dictate list: dysplasia; cholangitis; stones; primary sclerosing cholangitis; other ____]

E6b Distal Bile Duct Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 7th Ed.)

Tumor Size: A2 ____ x ____ x ____ cm

Tumor Site: ___ [select all that apply from the following: Common bile duct, intrahepatic or extrahepatic; other …]

Histologic type: E7a Carcinoma in situ E7b Adenocarcinoma, NOSE7d Clear cell adenocarcinomaE7e Mucinous carcinomaE7f Signet ring cell carcinoma E7g Squamous cell carcinomaE7h Adenosquamous carcinomaE7i Papillary carcinoma E7j Small cell carcinomaE7p Biliary cystadenocarcinomaE7k Undifferentiated carcinoma

[distinguish spindle and giant cell types]E7m Other: ______ [Note: Sarcomas and Carcinoids are Not included w/ this TNM staging]

Histologic grade: A18x GX: Cannot be assessed>95% glands A18a G1: Well differentiated50-95% glands A18b G2: Moderately differentiated<50% glands A18c G3: Poorly differentiated

A18d G4: Undifferentiated

Extent of invasion: A20x pTX: Cannot be assessedA20 pT0 [No evidence of primary tumor]A20i pTis [Carcinoma in situ; Epithelium only]A21 pT1 [Tumor confined to the bile duct histologically]A22 pT2 [Tumor invades beyond the wall of the bile duct]A23 pT3 [Tumor invades either: gallbladder, pancreas,duodenum or other adjacent organs w/o

Involvement of celiac axis or superior mesenteric artery]A24 pT4 [Tumor invades celiac axis or superior mesenteric artery]

Regional lymph nodes: A6x pNX: Cannot be assessedA6 pN0: No tumor noted in ___ nodes [fill in the blank with the number of nodes]A7 pN1: Tumor present in ___ of ___ nodes







Perineural invasion: A29a Not identified A29b Present

Additional findings: A13a None identifiedA13b [dictate list, example: dysplasia; cholangitis; stones; Primary Sclerosing Cholangitis; other ____]

Intrahepatic Bile Ducts: Resection 37E6a Intrahepatic Bile Duct Tumor Staging Information (data derived from current specimen; in accord with the AJCC

Cancer Staging Manual, 7th Ed.)

Tumor size: A2 ____ x ____ x ____ cm

Histologic type: E8a CholangiocarcinomaE8b Combined hepatocellular and cholangiocarcinomaE8c Bile duct cystadenocarcinomaE8d Other: ______ [Note: Sarcomas and Carcinoids are Not included w/ this TNM staging]

Growth pattern: [for intrahepatic cholangiocarcinoma only; see Notes below]E9a Mass-forming typeE9b Periductal infiltrating typeE9c Mixed mass-forming/periductal type

Histologic grade: A18x GX: Cannot be assessedA18a G1: Well differentiatedA18b G2: Moderately differentiatedA18c G3: Poorly differentiatedA18d G4: Undifferentiated

Extent of invasion: A20x pTX: Cannot be assessedA20 pT0 [No evidence of primary tumor]A20i pTis [Carcinoma in situ; Intraductal tumor]A21 pT1 [Solitary tumor without vascular invasion]A22a pT2a [Solitary tumor with vascular invasion]A22b pT2b [Multiple tumors, with or without vascular invasion]A23 pT3 [Tumor perforating the visceral periteum

OR Involving the local extra hepatic structures by direct invasion]

A24 pT4 [Tumor with periductal invasion] Note: T4 includes the diffuse periductal infiltrating and the mixed mass forming and periductal infiltrating tumor types.

Regional lymph nodes: A6x pNX: Cannot be assessedA6 pN0: No tumor noted in ___ nodes [fill in the blank with the number of nodes]A7 pN1: Tumor present in ___ of ___ nodes







Additional findings: A13a None identifiedA13b [dictate list, example: dysplasia; cholangitis; stones; other ____]

Notes:Tumor Growth Patterns of Cholangiocarcinoma:

60% - Mass-forming type. 20% - Periductal-infiltrating type - diffuse longitudinal growth pattern along the bile duct; poor prognosis20% - Mixed mass-forming/periductal-infiltrating type.

Fallopian Tube: resection 17F1 Fallopian Tube Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 7th Ed.)

Tumor size: A2 ____ x ____ x ____ cm

Tumor location: F4a Fimbria(e) F4d Interstitial portionF4b Ampulla F4e Combination [specify: ____ ]F4c Isthmus

Specimen Integrity, ___ side [specify]: F5a IntactF5b RupturedF5c FragmentedF5d Other [specify]: _____

Histologic type: F3a Carcinoma in situF3b Adenocarcinoma in situF3c Endometrioid adenocarcinomaF3d Clear cell adenocarcinomaF3e Mucinous adenocarcinomaF3f ___ cystadenocarcinoma [designate serous or mucinous]F3g Transitional cell carcinomaF3h Squamous cell carcinomaF3i Undifferentiated carcinomaF3j Other, specify: ________


Summary of Organs/ Tissues Microscopically Involved by Tumor [this is an optional reporting element]:F6 [specify all organs or tissues involved, possibly including: Fallopian tube only // Fallopian tube(s) //

Cervix // Uterine corpus // Vagina // Vulva // Ovaries // Bladder // Rectum // etc. ]

TNM (FIGO): F9x pTX (--): Cannot be assessedF9 pT0 (--) [No evidence of primary tumor]F11 pT1 (I) [Tumor limited to fallopian tube(s)]F11a pT1a (IA) [Tumor limited to one tube without penetration of serosal surface; no ascites]F11b pT1b (IB) [Tumor limited to both tubes without penetration of serosal surface; no ascites]F11c pT1c (IC) [Tumor limited to one or both tubes with extension into or through the tubal

surface; or, with malignant cells in ascites or peritoneal washings]F2 pT2 (III) [Tumor involves one or both tubes with pelvic extension]F12a pT2a (IIA) [Extension and/or metastasis to the uterus and/or ovaries]F12b pT2b (IIB) [Extension to other pelvic structures]F12c pT2c (IIC) [Pelvic extension (pT2a or b) with malignant cells in ascites or peritoneal washings]F13 pT3 (III) [Tumor involves one or both tubes with peritoneal implants outside the

pelvis and/or regional lymph node metastasis]F13a pT3a (IIIA) [Microscopic peritoneal metastasis beyond pelvis]F13b pT3b (IIIB): [Macroscopic peritoneal metastasis beyond pelvis < 2 cm in greatest diameter]F13c pT3c (IIIC): [Macroscopic peritoneal metastasis beyond pelvis > 2 cm in greatest diameter

and/or regional lymph node metastasis] Notes: 1. If there is a non-peritoneal met, change the FIGO to IV, whatever the TNM stage is. (Ex., a liver capsule met is

T3/FIGO III. A liver parenchymal met is M1/FIGO IV.) 2. If there is a lymph node met (N1), change the FIGO to IIIC unless it is FIGO IV, whatever the TNM stage is.

Regional lymph nodes: A6x pNX: Cannot be assessedA6 pN0: No tumor noted in ___ nodesA9f pN1(FIGO IIIC): Tumor present in ___ of ___ nodes

Distant metastasis: A10x pMX: Cannot be assessedA10 pM0: No distant metastasis

A11 pM1 (FIGO IV): Present, involving: _____

18Margin evaluation: A28x RX [presence of residual tumor cannot be assessed]

A28 R0: Margins free of tumor. Distance of tumor from closest margin: ____ cm ( ____margin)[Complete resection, no residual tumor left after resection]

A28a R1: ____ margin involved by microscopic tumor[Incomplete resection, margins involved by microscopic tumor]

A28b R2: ____ margin involved by tumor [Incomplete resection; gross tumor at margin]


Additional findings: A13a None identifiedA13b [dictate list: ex., salpingitis (type: ____); dysplasia; other, ____Note: your report

should state what organs are involved by direct extension and / or by metastasis, including assessments of : Uterine cervix, Uterine corpus, Vagina, Vulva, Fallopian

tubes, Ovaries, Bladder, RectumIf an independent primary tumor is present, use a second section with the appropriate staging information

Notes:

Site(s) of origin of tumor. Recent data suggests that the fallopian tube may be the primary source for many tumors historically assigned to ovary or peritoneum. Traditionally, tumor origin has been based on the location of the bulk of the tumor, with ovarian carcinoma demonstrating predominant involvement of the ovarian parenchyma, whereas the salpinx is implicated if the tumor is centered mainly in the tube with minimal ovarian surface involvement. Primary peritoneal carcinoma requires the presence of extensive and predominant peritoneal disease with normal ovaries or involvement confined to ovarian serosal surface or cortical invasion limited to 5 mm by 5 mm. In the presence of diffuse disease, if tubal intraepithelial carcinoma is present, these should now be regarded as tubal carcinomas. The distal fallopian tube appears to be most frequently involved in cases of early serous carcinoma, so this requires processing of the fimbriated end of the fallopian tube (see Figure). In cases of diffuse serous carcinoma, tumor implants may also be seen on the tubal mucosa, making definitive assessment of tubal intraepithelial carcinoma impossible. In such cases, the phrase “serous carcinoma of tubal/ovarian origin” may be used.

Figure. Protocol for Sectioning the Fallopian Tube in cases of diffuse serous carcinoma: entails longitudinal sectioning of the infundibulum and fimbrial segment (distal 2 cm) while the isthmus and ampulla are cut transversely at 2- to 3-mm intervals.

Inflammation: Carcinoma is rarely associated with severe salpingitis. Therefore, the presence of severe inflammation should alert the pathologist to the possibility of a pseudocarcinomatous change.

34 Gallbladder or Cystic Duct: resection F33 Gallbladder Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 7th Ed.)F33a Cystic Duct Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 7th Ed.)

Tumor size: A2 ____ x ____ x ____ cmTumor site: C2a ____ [select all that apply: fundus; body; neck; cystic duct; free peritoneal side of gallbladder;

hepatic side of gallbladder]Histologic type: F34a Carcinoma in situ

F34b Papillary adenocarcinoma[Carcinoid tumors F34c Adenocarcinoma [add if appropriate: , intestinal type; , clear cell type; , signet ring cell type] & Sarcomas not F34d Mucinous carcinoma included] F34f Adenosquamous carcinoma

F34g Small cell carcinomaF34h Undifferentiated carcinoma [add if appropriate: , spindle cell type; , giant cell type]F34j CarcinosarcomaF34k Other: specify _____

Histologic grade: A18x GX: Cannot be assessedA18a G1: Well differentiated [ > 95% gland forming]A18b G2: Moderately differentiated [50-95 % gland forming]A18c G3: Poorly differentiated [5-49 % gland forming]A18d G4: Undifferentiated [< 5 % gland forming]

Extent of invasion: A20x pTX [Cannot be determined]A20 pT0 [No evidence of primary tumor]A20i pTis [Carcinoma in situ]A21 pT1 [Tumor invades lamina propria or muscle layer]A21a pT1a [Tumor invades lamina propria]A21b pT1b [Tumor invades muscle layer]A22 pT2 [Tumor invades perimuscular connective tissue; no peritoneal perforation or liver

extension]A23 pT3 [Tumor perforates serosa (visceral peritoneum) and/or directly invades the liver and / or

one other adjacent organ or structure, such as the stomach, duodenum, colon, or pancreas, omentum or extra-hepatic bile ducts]

A24 pT4 [Tumor invades main portal vein or hepatic artery or invades multiple extrahepatic organs or structures]

Regional lymph nodes: A6x pNX: Cannot be assessedA6 pN0: No tumor noted in ___ nodesA7 pN1: Tumor present in ___ of ___ nodes [mets to nodes along cystic duct, common bile duct,

hepatic artery, and/or portal vein]A8 pN2: Tumor present in ___ of ___ nodes [mets to periaortic, pericaval, superior mesenteric

artery, and/or celiac artery lymph nodes]





Note: Margins to be examined include: non-peritonealized surface (liver bed) and cystic duct margin



Additional findings: A13a None identifiedA13b [dictate list: ex., dysplasia/adenoma; cholecystitis; cholelithiasis; other, ____ ]

48Gastrointestinal Lymphoma: resection

F56 Gastrointestinal Lymphoma Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 6th Ed.)

To be completed later

Heart: resection 67H1 Heart Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 6th Ed.)


47Hodgkin’s Disease: resection

H13 Hodgkin’s Disease Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 6th Ed.)


K1 Kidney Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer 5 Staging Manual, 7th Ed.)

Laterality: K5a RightK5b LeftK5c Not specified

Tumor size: A2 ____ x ____ x ____ cm

Histologic type: K2a Cannot be determined K2f Tubulocystic renal cell carcinomaK2b Clear cell renal cell carcinoma K2g Collecting duct carcinomaK2c Multilocular clear cell renal cell carcinoma K2h Renal medullary carcinomaK2d Papillary renal cell carcinoma, subtype __ [‘1’ or ‘2’] K2i Other, (specify: _____ )K2e Chromophobe renal cell carcinoma

Sarcomatoid features: K2x Not identified [See Notes below]K2y Present, ___ %.

Histologic grade (Fuhrman nuclear grade): [Note: Scoring is based on the worst (highest) grade present in thetumor even if it constitutes only a minor component]

K6x GX: Cannot be assessedK6a G1 [Nuclei round, uniform, approximately 10u; nucleoli inconspicuous or absent]K6b G2 [Nuclei slightly irregular, approximately 15u; nucleoli evident]K6c G3 [Nuclei very irregular, approximately 20u; nucleoli large and prominent]K6d G4 [Nuclei bizarre and multilobated, 20u or greater, nucleoli prominent, chromatin clumped]

Extent of invasion: A20x pTX Cannot be assessedA20 pT0 No evidence of primary tumorA21 pT1 [Tumor < 7.0 cm in greatest dimension limited to the kidney]A21a pT1a [Tumor < 4.0 cm in greatest dimension limited to the kidney]A21b pT1b [Tumor > 4.0 cm and < 7.0 cm in greatest dimension limited to the kidney]A22 pT2 [Tumor > 7.0 cm in greatest dimension limited to the kidney]A22a pT2a [Tumor > 7.0 cm and < 10.0 cm in greatest dimension limited to the kidney]A22b pT2b [Tumor > 10.0 cm in greatest dimension limited to the kidney]A23 pT3 [Tumor extends into major veins or perinephric tissues but not beyond Gerota’s fascia

and not into the ipsilateral adrenal gland]A23a pT3a [Tumor grossly extends into the renal vein(s) or its segmental (muscle-containing)

branches, or tumor invades perirenal and/or renal sinus fat, but not beyond Gerota’s fascia]

A23b pT3b [Tumor grossly extends into the vena cava below the diaphragm]A23c pT3c [Tumor grossly extends into the vena cava above the diaphragm or invades the wall of

the vena cava]A24 pT4 [Tumor invades beyond Gerota’s fascia (including contiguous extension into the

ipsilateral adrenal gland)]

Regional lymph nodes: A6x pNX: Cannot be assessedA6 pN0: No tumor noted in ____ nodesA7 pN1: Tumor present in ___ of ___ nodes

Distant metastasis: A10x pMX: Cannot be assessedA10 pM0: No distant metastasisA11 pM1: Present, involving: _____ [includes noncontiguous adrenal gland involvement]

Margin evaluation: A28x RX [presence of residual tumor cannot be assessed] A28 R0: Margins free of tumor. Distance of tumor from closest margin: ____ cm ( ____margin)



Note: R0, R1 and R2 margins include examination of: Renal capsular margin ; Renal sinus margin (see notes below); Renal vein margin; Gerota’s fascial margin; Ureteral margin.

Lymph-Vascular invasion (excluding renal vein and inferior vena cava): [also excludes muscle containing segmental B30x Indeterminate branches of renal vein; these areB30 Not identified all covered by pT staging]B30a Present

Adrenal Gland: [only if present] K4 Uninvolved by tumor K4a Involved by tumor by direct invasion (pT3a) K4b Involved by tumor metastasis (pM1)

Additional findings: A13a None identified A13b [dictate list: ex., inflammation; glomerular disease; interstitial disease (type: _____ ); other]

Notes:Diagram showing relationship between local tumor extension and pT designation. When a tumor shows direct invasion into the perirenal fat or renal sinus fat it is designated as pT3a. [The renal sinus fat and its rich venous system envelop the collecting system. The renal sinus fat should be carefully assessed andgenerously sampled in order to detect renal sinus fat involvement. There is evolving literature suggesting that renal sinus fat involvement predicts a moreaggressive outcome than peripheral perinephric fat invasion.] The renal capsule terminates just inside the vestibule of the hilus.

Adrenal gland: When renal carcinoma involves adrenal gland, it is important to document whether therenal tumor directly invades the adrenal gland (pT4) or is a separate (noncontiguous) nodule of carcinoma, the latter representing metastatic disease (pM1).

Occasionally more than one histologic type of carcinoma occurs within the same kidney specimen. Each tumor type should be separately recorded along with its associated prognostic factors.

Sarcomatoid Features: a pattern of dedifferentiation. Sarcomatoid change in a renal cell carcinoma is associated with an adverse outcome and may be found in renal cell carcinomas of clear cell, papillary, chromophobe, collecting duct, and unclassified subtypes. Pure sarcomatoid carcinoma or sarcomatoidcarcinoma associated with epithelial elements that do not conform to usual renal carcinoma cell types should beconsidered as unclassified renal cell carcinoma.

Pathologic Findings in Nonneoplastic Kidney It is important to recognize medical kidney diseases may be present in nonneoplastic renal tissues: Arterionephrosclerosis (or hypertensive nephropathy) and diabetic nephropathy are seen in approximately 30% and 20% of cases, respectively. Other medical renal diseases that have been identified include thrombotic microangiopathy, focal segmental glomerulosclerosis, and IgA nephropathy. The findings of greater than 20% global glomerulosclerosis or advanced diffuse diabetic glomerulosclerosis are predictive of significant decline in renal function 6 months after radical nephrectomy. Evaluation for medical renal disease should be performed in each case; PAS and/or Jones methenamine silver stains should applied if necessary.

33Note: Hepatocellular ca only – doesn’t include sarcoma. See new cholangiocarcinoma section for bile duct & mixed tumors.

L20 Liver Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 7th Ed.)

Tumor size: A2 ____ x ____ x ____ cm

Histologic type: L21 Cannot be assessedL21a Hepatocellular carcinoma, NOSL21b Fibrolamellar variant of hepatocellular carcinoma [see Note: below]L21e Other, specify: ____

Histologic grade (Edmonson & Steiner system): [see Note: below]A18x GX: Cannot be assessedA18a G1: Well differentiatedA18b G2: Moderately differentiatedA18c G3: Poorly differentiatedA18d G4: Undifferentiated

Nuclear grade: L13a 1 [little variation in size and shape; closely similar to benign nuclei; no prominent nucleoli]L13b 2 [large nuclei; mild to moderate pleomorphism; prominent nucleoli; chromatin clumping]

[see photos below] L13c 3 [larger nuclei w/ distinct pleomorphism & prominent nucleoli; includes tumors with giant or multinucleated tumor cells] Ref: AJSP, vol 26, pg. 25-34, 2002.

Extent of invasion: A20x pTX: Cannot be assessedA20 pT0: No evidence of primary tumorA21 pT1 [Solitary tumor, regardless of size, without vascular invasion]A22 pT2 [Solitary tumor, regardless of size, with vascular invasion of minor vessels (see pT3b)

or Multiple tumors all < 5 cm in diameter]

A23 pT3 [either of the following]A23a pT3a [Multiple tumors, if any >5 cm in diameter]A23b pT3b [Tumor, regardless of size, involving a major branch of the portal or hepatic vein(s)]A24 pT4 [Tumor(s) with direct invasion of adjacent organs other than the gallbladder

or With perforation of visceral peritoneum]


Fibrosis: L19a F0 Ishak score __ [scale 0-4: none to moderate fibrosis]L19b F1 Ishak score __ [scale 5-6: severe fibrosis to cirrhosis]

Degree of Fibrosis (Ishak scoring system) Score None 0 Fibrous expansion of some portal areas, with or without short fibrous septa 1 Fibrous expansion of most portal areas 2 Fibrous expansion of most portal areas with occasional portal-portal bridging 3 Fibrous expansion of portal areas with marked bridging as well as portal-tocentral bridging 4 Marked bridging with occasional nodules (incomplete cirrhosis) 5 Cirrhosis 6

Mitotic count: L14a low mitotic activity [ < 7 mitoses per 10 HPF] #’s adjusted for our scopes; give # in microL14b high mitotic activity [ > 8 mitoses per 10 HPF] ref: AJSP, vol 26, pg. 25-34, 2002.





Vascular/Lymphatic vessel invasion: B30x IndeterminateB30 Not identifiedB30a Present [If present, note in the micro whether it was macrovascular or

microvascular, the latter including portal veins, central veins, or vessels running through a capsule]

Additional findings: A13a None identifiedA13b [dictate list: ex., hepatocyte dysplasia; ductal dysplasia; cirrhosis/fibrosis; iron overload;

hepatitis (type: _____); other, ____

Notes:

Histologic type: Multiple histologic architectural patterns, such as trabecular, solid, and pseudoglandular patterns, are often found in the same tumor in hepatocellular carcinoma, but only the fibrolamellar variant appears to have prognostic significance (although the relatively longer survival for this variant may relate to its occurrence in younger patients and in the noncirrhotic liver). Tumors that contain areas of both fibrolamellar carcinoma and typical hepatocellular carcinoma should be classified simply as hepatocellular carcinoma. The term fibrolamellar variant of hepatocellular carcinoma should be reserved for those tumors showing only the fibrolamellar pattern.

Edmondson and Steiner Grading of Hepatocellular Carcinoma

Grade I where the difference between the tumor cells and hyperplastic liver cells is so minor that a diagnosis ofcarcinoma rests upon the demonstration of more aggressive growths in other parts of the neoplasm.

Because grade is assigned based upon the highest grade present, in effect grade I is rarely if ever used

for overall tumor grade designation.

Grade II Cells show marked resemblance to normal hepatic cells. Nuclei are larger and more hyperchromatic than in normal cells. Cytoplasm is abundant and acidophilic. Cell borders are sharp and clear cut. Acini are frequent and variable in size. Lumina are often filled with bile or protein precipitate.

Grade III Nuclei are larger and more hyperchromatic than in grade II cells. The nuclei occupy a relatively greater proportion of the cell (high nuclear to cytoplasmic [N:C] ratio). Cytoplasm is granular and

acidophilic, but less so than grade II tumors. Acini are less frequent and not as often filled with bile or protein precipitate. More single-cell growth in vascular channels is seen than in grade II.

Grade IV Nuclei are intensely hyperchromatic. Nuclei occupy a high percentage of the cell. Cytoplasm is variable in amount and often scanty. Cytoplasm contains fewer granules. The growth pattern is medullary in

character, trabeculae difficult to find, and cell masses seem to lie loosely without cohesion in vascular

channels. Only rare acini are seen. Spindle cell areas have been seen in some tumors. Short plump cell forms, resembling “small cell” carcinoma of the lung, are seen in some grade IV tumors.

Nuclear Grade:

Lung: resection 7L1 Lung Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 7th Ed.)Tumor size: A2 ____ x ____ x ____ cm

Histologic type: L2 Squamous cell carcinomaL2a Squamous cell carcinoma, ___ subtype [variants include: Papillary, Clear cell, Small cell, Basaloid]L3 Small cell carcinomaL3a Combined small cell carcinoma [small cell ca & non-small cell ca component (specify type)]L4 AdenocarcinomaL4a Adenocarcinoma, acinar subtypeL4b Adenocarcinoma, papillary subtypeL4c Adenocarcinoma, bronchiolo-alveolar subtype [limited to non-invasive tumor (i.e., requires review of

entire tumor, with no stromal, vascular or pleural invasion) tumors with lepidic spread; var. include Non-mucinous type, Mucinous type, & Mixed mucinous and non-mucinous]

L4d Adenocarcinoma, solid subtype with mucin formation [need to see 5 well defined foci of cytoplasmic mucin per 2 HPF to call it this]

L4e Adenocarcinoma, mixed subtype [most common; ex. If you have an adenocarcinoma with invasionand an extensive bronchiolo-alveolar pattern, diagnose as Adenocarcinoma, mixed subtype with predominant bronchioloalveolar patter and focal acinar, solid or papillary pattern, depending on which pattern is seen in the invasive component]

L4f ___ adenocarcinoma [less common var. include Fetal adenoCa (called blastomas in the past), Mucinous adenoCa, Mucinous cystadenoCa, Signet ring adenoCa, Clear cell adenoCa]

L5 Large cell carcinomaL5a Large cell neuroendocrine carcinoma [> 11 mitoses/10 HPF; cell dia > 3 lymph dia; if immunos are

negative for neuroendocrine markers, some still recommend calling it Large cell ca w/ neuroendocrine morphology]

L5b ___ carcinoma [other var. of large cell ca: Combined large cell neuroendocrine ca, Basaloid ca,Lympho- epithelioma-like ca (esp SE Asia), clear cell ca, & Large cell ca w/ rhabdoid phenotype]

L6 Adenosquamous carcinoma [need at least 10% of both components]L7 Pleomorphic carcinoma [biphasic tumors w/ carcinomatous as well as spindle and/or giant cells

components -- ex. Pleomorphic carcinoma w/ spindle and giant cell differentiation, or Pleomorphic carcinoma w/ adenocarcinoma and giant cell differentiation]

L7a Carcinosarcoma [biphasic tumors with carcinomatous and heterologous sarcomatous elements (ie., bone, cartilage or skeletal muscle)]

L8 Carcinoid tumorL8a Typical carcinoid tumor [< 2 mitoses/ 10 HPF and no necrosis]L8b Atypical carcinoid tumor [2-10 mitoses / 10 HPF or foci of necrosis (a punctate comedoform look)]L9 Bronchial gland carcinomaL9a Bronchial gland carcinoma, adenoid cystic typeL9b Bronchial gland carcinoma, mucoepidermoid typeL10 Other, specify [the above list does not include a variety of other soft tissue, mesothelial, lymphoprolif., etc.]

Histologic grade: A18x GX: Cannot be assessedA18a G1: Well differentiated [Note: if there are variations in grade, use least favorable grade]A18b G2: Moderately differentiatedA18c G3: Poorly differentiatedA18d G4: Undifferentiated [includes small cell ca and large cell ca, by definition]

Extent of invasion: A20x pTX: Cannot be assessed [or tumor proven by presence of malignant cells in sputum or bronchial washings but not visualized by imaging or bronchoscopy]

A20 pT0 [No evidence of primary tumor] A20i pTis [Carcinoma in situ] A21a pT1a [Tumor < 2cm in greatest dimension, surrounded by lung or visceral pleura, without

bronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e., not in the main bronchus)],

OR, [Superficial spreading tumor of any size with its invasive component limited to the bronchialwall, which may extend proximally to the main bronchus]

A21b pT1b [Tumor >2 cm but < 3cm in greatest dimension, surrounded by lung or visceral pleura, withoutbronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e., not in the main bronchus)]

A22a pT2a [Tumor >3 cm but < 5 cm in greatest dimension, surrounded by lung or visceral pleura, withoutbronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e., not

in the main bronchus)],

8 OR, [Tumor < 5 cm in greatest dimension with any of the following:involves the main bronchus > 2 cm from the corina invades the visceral pleura associated with atelectasis or obstructive pneumonitis that extends to the hilar region but does not involve the entire lung

A22b pT2b [Tumor >5 cm but < 7 cm in greatest dimension] A23 pT3 [Tumor > 7 cm in greatest dimension],

OR [Tumor of any size that directly invades any of the following:chest wall (including superior sulcus tumors)diaphragm or phrenic nervemediastinal pleuraparietal pleura or parietal pericardium

OR [Tumor of any size in the main bronchus < 2 cm distal to the carina but w/o carinal involvement] OR [Tumor of any size associated with atelectasis or obstructive pneumonitis of the entire lung] OR [Tumor of any size with separate tumor nodule(s) of similar histology in the same lobe]

A24 pT4 [Tumor of any size that invades any of the following:mediastinumheartgreat vesselstrachea

esophagusvertebral bodycarinavisceral pericardium

OR [Tumor of any size with separate tumor nodule(s) in a different lobe of the same lung]

Regional lymph nodes: A6x pNX: Cannot be assessedA6 pN0: No tumor noted in ___ nodesA7 pN1: Tumor present in ___ of ___ nodes [Mets in ipsilateral peribronchial, hilar or

intrapulmonary nodes, including involvement by direct extension]A8 pN2: Tumor present in ___ of ___ nodes [Mets in ipsilateral mediastinal and/or

subcarinal lymph node(s)]A9 pN3: Tumor present in ___ of ___ nodes [Mets in contralateral mediastinal,

contralateral hilar, ipsilateral or contralateral scalene or supraclavicular node(s)]

If (+) nodes present, add: Size of largest nodal metastasis: B27 ____ cm

Extranodal tumor extension: B28a NoB28b Yes [Direct extension of a primary tumor into a nearby

lymph node does not qualify as extranodal extension.]Nodal station(s) involved by tumor: B28c _____ [see diagram page and/or clinical hx]

Distant metastasis: A10x pMX: Cannot be assessedA10 pM0: No distant metastasisA11a pM1a: Present, involving: _____[separate tumor nodule(s) in contralateral lobe OR tumor with

pleural nodules, malignant pleural (or pericardial) effusion (note: most pleural effusions with lung cancer are due to tumor. If, however, the fluid is non-bloody, notan exudate, and multiple cytopathologic examinations of pleural fluid are tumor negative, the effusion should be excluded as a staging element]

A11b pM1b: Present, involving: _____[distant metastasis outside the lung and pleura]




Note: Margins to examine for R0, R1 and R2 include: Bronchial, vascular, parenchymal, & attached tissue margins.

Pleural involvement by tumor: L12a Indeterminate [see note below]L12b No – PL0 L12c Yes – PL1 (tumor penetration of elastic layer of visceral pleura)L12d Yes – PL2 (tumor extension to visceral pleural surface)

Vascular/Lymphatic vessel invasion: B30x IndeterminateB30 Not identified

B30a Present

Treatment effect: [for carcinomas treated with neoadjuvant therapy – this is adapted from one for colon] C8a Grade 0: Complete response; no residual tumor noted.C8b Grade 1: Moderate response; minimal residual tumor noted.C8c Grade 2: Minimal response.C8d Grade 3: No definite response identified.

Additional findings: A13a None identifiedA13b [dictate list: ex., metaplasia (type: ____ ); dysplasia; inflammation (type: ____ ); other, ____

NotesVisceral Pleural Invasion: is present if:

1. Type PL1 - Tumor extends to the visceral pleural surface2. Type PL2 - Tumor penetrates beyond the elastic layer of the visceral pleura (see photos below). Elastic stains may help.

Pleural tumor involvement in foci separate from direct pleural invasion should be categorized as pM1a. Tumor with local invasion of another ipsilateral lobe without tumor on the pleural surface should be classified as T2. Pleural involvement by tumors < 3cm increases the stage from pT1 to pT2.

Types of visceral pleural invasion. A and B, Visceral pleural invasion is present when a tumor penetrates beyond the elastic layer of the visceral pleura (type PL1 pleural invasion). C, Tumor extension to the visceral pleural surface is also categorized as visceral pleural invasion (type PL2). Both types of visceral pleural invasion raise the T category of otherwise T1 tumors to T2. D, Visceral pleural invasion is categorized as absent in tumors that do not penetrate the visceral pleural elastic layer (type PL0)

Tumor Focality. Generally, if separate tumors of similar histology are in the same lobe stage it as pT3. Separate tumors of similar histology in separate lobes are pT4. They are considered intrapulmonary mets. However, if they have similar histology but no obvious metastatic path (i.e., they both show an origin from CIS, with no carcinoma in lymphatics common to both tumors, and no extrapulmonary metastases at the time of diagnosis), they should be categorized as synchronous primary carcinomas and staged independently. Needless to say, if you have physically distinct and separate tumors of different histologic types, these are generally considered separate, synchronous primaries and are staged separately. In such cases, the highest T category is reported, followed in parentheses by ‘m’ for multiplicity or by the number of tumors (e.g., T2(m) or T2(5)).

Pulmonary Nodes – Grading N1 - Metastasis to ipsilateral peribronchial and/or ipsilateral hilar lymph nodes, and intrapulmonary nodes including involvement by direct extension of the primary tumor.

These are nodes designated by the surgeons as:N10 Hilar nodes N13 Segmental nodesN11 Interlobar nodes N14 Subsegmental nodesN12 Lobar nodes bronchi

N2 - Metastasis to ipsilateral mediastinal and/or subcarinal lymph nodes.These are nodes designated by the surgeons as: N1 Highest mediastinal nodes N6 Para-aortic nodes (ascending or phrenic)N2 Upper paratracheal nodes N7 Subcarinal nodesN3 Prevascular & retrotracheal nodes N8 Paraesophageal nodes (below carina)N4 Lower paratracheal nodes N9 Pulmonary ligament nodesN5 Subaortic nodes (aorto-pulm window)

N3 - Metastasis to contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene,

or supraclavicular lymph nodes.

Lymphoma, Non-Hodgkin’s: Biopsy or resection 45L43 Lymphoma Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 6th Ed.)


Ovary 19F25 Ovarian Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 7th Ed.)F25a Extraovarian Peritoneal Carcinoma Staging Information (data derived from the current specimen; in accord

with the AJCC Cancer Staging Manual, 7th Ed.) [see Note at end]

Tumor size: F26a ____ x ____ x ____ cm [single tumor mass]F26b ____ x ____ x ____ cm; tumor fragments in aggregate

Specimen Integrity, ___ side [specify]: F5a IntactF5b RupturedF5c FragmentedF5d Other [specify]: _____

Histologic type:Surface Epithelial-Stromal Tumors include:

F27a Borderline serous tumor F27c Borderline mucinous tumorF27b Serous carcinoma F27d Mucinous carcinoma

F27e Borderline endometrioid tumor F27g Borderline clear cell tumorF27f Endometrioid carcinoma F27h Clear cell carcinoma

F27i Borderline transitional cell tumor F27k Squamous cell carcinomaF27j Transitional cell carcinoma F27L Undifferentiated carcinoma

F27m Mixed epithelial carcinoma [specify proportions: ______] [See Notes below]

Sex-cord Stromal Tumors include:F27n Granulosa cell tumor

Germ Cell Tumors include:F27p [specify type: ______](i.e., Dysgerminoma; Yolk sac tumor; Immature teratoma; Mixed malignant germ

cell tumor [specify types]; Malignancy in dermoid cyst[specify type])for everything else:

F27p Other (specify type and proportions as appropriate)


TNM (FIGO): F9x pTX (--): Cannot be assessedF9 pT0 (--) [No evidence of primary tumor]F11 pT1 (I) [Tumor limited to ovaries (one or both)]F11a pT1a (IA) [Tumor limited to one ovary: capsule intact, no tumor on ovarian

surface. No malignant cells in ascites or peritoneal washings.]F11b pT1b (IB) [Tumor limited to both ovaries: capsule intact, no tumor on ovarian

surface. No malignant cells in ascites or peritoneal washings.]F11c pT1c (IC) [Tumor limited to one or both ovaries with any of the following: capsule ruptured,

tumor on ovarian surface, malignant cells in ascites or peritoneal washings]F12 pT2 (II) [Tumor involves one or both ovaries with pelvic extension.] F12a pT2a (IIA) [Tumor extends and / or implants on uterus and / or tube(s). No malignant cells in ascites

or peritoneal washings.]F12b pT2b (IIB) [Tumor extends to other pelvic tissues. No malignant cells in ascites or peritoneal washings.]F12c pT2c (IIC) [Pelvic extension by tumor (pT2a or b) with malign. cells in ascites or peritoneal washings]

F13 pT3 (III) [Tumor involves one or both ovaries with microscopically confirmed peritoneal metastasis

outside the pelvis and / or regional lymph node metastasis]F13a pT3a (IIIA) [Microscopic peritoneal metastasis beyond the pelvis]F13b pT3b (IIIB) [Macroscopic peritoneal metastasis beyond pelvis < 2 cm in greatest dimension]F13c pT3c (IIIC) [Peritoneal metastasis beyond pelvis > 2 cm in greatest dimension and / or regional lymph

node metastasis]Notes: 1. if tumor also has a distant met, change the FIGO stage to IVB, whatever the TNM stage is.

2. a liver capsule met is pT3/FIGO III. But a liver parencymal met or (+) pleural effusion is M1/FIGO IV.

20Ovarian surface involvement by tumor: F16x Uncertain/cannot be determined

F16a AbsentF16b Present

Implants: [Note: only applies to advanced stage serous or seromucinous borderline tumors]F17a AbsentF17b Noninvasive implants present, involving ___ [these may be of epithelial or desmoplastic type]F17c Invasive implants present, involving ___


Distant metastasis: A10x pMX: Cannot be assessedA10 pM0: No distant metastasis (does not include peritoneal metastasis or regional lymph node mets)A11 pM1: Present, involving: _____




Summary of Organs/ Tissues Microscopically Involved by Tumor [this is a required reporting element]:F6 [specify all organs or tissues involved, possibly including: R and/or L ovary // Uterus // Vagina // Vulva // Omentum

// R and/or L Fallopian tube // Bladder // Rectum // R and/or L Broad Ligament // Peritoneum // other organs/tissues (specify all) Note: your report should state what organs are involved by direct extension and / or by met]


Additional findings: A13a None identifiedA13b [dictate list, example: endometriosis (ovarian, extraovarian); endosalpingiosis; other ____

Notes:Site(s) of origin of tumor. Recent data suggests that the fallopian tube may be the primary source for many tumors historically assigned to ovary or peritoneum. Traditionally, tumor origin has been based on the location of the bulk of the tumor, with ovarian carcinoma demonstrating predominant involvement of the ovarian parenchyma, whereas the salpinx is implicated if the tumor is centered mainly in the tube with minimal ovarian surface involvement. Primary peritoneal carcinoma requires the presence of extensive and predominant peritoneal disease with normal ovaries or involvement confined to ovarian serosal surface or cortical invasion limited to 5 mm by 5 mm. In the presence of diffuse disease, if tubal intraepithelial carcinoma is present, these should now be regarded as tubal carcinomas. The distal fallopian tube appears to be most frequently involved in cases of early serous carcinoma, so this requires processing of the fimbriated end of the fallopian tube (see Figure under Fallopian Tube). In cases of diffuse serous carcinoma, tumor implants may also be seen on the tubal mucosa, making definitive assessment of tubal intraepithelial carcinoma impossible. In such cases, the phrase “serous carcinoma of tubal/ovarian origin” may be used.

There are several criteria to help determine the primary origin of the tumor. Size and distribution of the tumors, presence of a precancerous lesion in either organ (atypical hyperplasia of the endometrium, endometriosis or adenofibroma of the ovary), microscopic appearance of the tumors, DNA ploidy findings, and molecular genetic studies have all been used to facilitate this differential diagnosis. Regardless, when synchronous low-grade endometrioid ovarian and endometrial carcinomas coexist, they are typically associated with good prognosis.

Distribution of tumor in the ovary may be a clue to its origin. If the tumor is mainly present on the surface of the ovary without forming a discrete lesion, the tumor is more likely to be a primary peritoneal neoplasm with secondary ovarian involvement. If a tumor is centered or mainly involves the ovarian hilus, it is most likely a metastasis or a primary tumor originating from some structure in this area.

Contralateral Ovary refers to the ovary that is nondominant, because it is either: (1) involved by a tumor that is similar to but smaller than the dominant ovarian tumor, (2) contains only what appears to be metastatic tumor on gross examination, or (3) is negative for tumor.

If the contralateral ovary contains only focal tumor, the gross and microscopic examination should concentrate on determining whether the tumor is an independent primary or it is metastatic from the dominant ovary. Metastatic involvement is supported by the same criteria that are used to distinguish primary and metastatic cancers to the ovary. (multiple nodules, surface implants, and hilar vascular space invasion favor metastasis).

Histologic Type1. For surface epithelial stromal tumors , surface involvement by neoplastic cells elevates the substage in

stage I tumors and indicates a higher likelihood of extraovarian peritoneal involvement.2. Mucinous tumors of the ovary , when bilateral, should be considered metastases until proven otherwise. 3. Bilateral, histologically well-differentiated tumors with pseudomyxoma peritonei are likely to be appendiceal in

origin. Only rare ovarian teratomas may be associated with pseudomyxoma ovarii.4. The term “mixed carcinoma” should only be used when 2 or more distinctive subtypes of surface epithelial

carcinomas are identified representing >10% of the tumor. When a carcinoma is classified as “mixed,” the major and minor types and their relative proportions should be specified. High-grade tumors with ambiguous features should be classified as “carcinoma, subtype cannot be determined”; however, this is a very infrequent situation and every effort should be made to subclassify such tumors.

5. Serous Tumors. Architectural features usually parallel nuclear features (ie, the extent of gland and papillae formation versus the quantity of solid growth correlates with low versus high grade). However, exceptions exist; for example certain tumors exhibit a solid growth pattern in the form of small nests associated with high degree of nuclear maturation and often containing numerous psammoma bodies. Tumors in the latter category are assigned grade 1 (or low grade) despite their solid architecture.

6. Mucinous Tumors. The main question is whether the tumor falls in the borderline or carcinoma category. Many mucinous tumors that lack obvious stromal invasion contain cysts and glands lined by malignant epithelium. Such tumors have been designated as borderline tumor “with intraepithelial carcinoma.” They appear to have an excellent prognosis.

7. Endometrioid Tumors. graded according to FIGO system suggested for tumors of the uterine corpus.Grade 1 ≤5% of a nonsquamous, solid growthGrade 2 6% to 50% of nonsquamous solid growthGrade 3 >50% of nonsquamous, solid growth

Note: Notable nuclear atypia, inappropriate for the architectural grade, raises the grade of a grade 1 or grade 2 tumor by one.

8. Adenocarcinomas with squamous differentiation are graded according to the nuclear grade of the glandular component.

9. Clear cell and transitional cell . In general, these tumors are all high grade.10. Squamous cell . Pure squamous cell carcinoma primary of the ovary is very rare. Such tumors can be graded in a

3-tier system.11. Germ Cell Tumors. Immature teratomas are the only malignant germ cell tumors that are graded. They are

classically graded on the basis of the quantity of immature/embryonal elements (almost always neuroectodermal tissue) that are present. Even though, in the past a 3-tier system was used to classify immature teratomas (G1=immature neural tissue occupying <1 low-power field in any slide and G3= immature neural tissue occupying < 4 low-power fields in any slide), recently, a 2-tiered grading system (low versus high grade) has been proposed by some experts. Also, implants associated with immature teratomas must be assessed for the presence of immature elements, typically glial tissue (gliomatosis peritonei).

12. Granulosa Cell Tumors. Even though two groups of investigators have found that nuclear grading is effective in determining prognosis in these tumors, the vast majority of gynecologic pathologists do not grade granulosa cell tumors because the most important prognostic parameter is stage.

Primary Peritoneal Adenocarcinoma: Cases with intraperitoneal carcinoma in which the ovaries appear to be incidentally involved and not the primary origin should be labeled as extraovarian peritoneal carcinoma. The clinical presentation, etc., mirror those of papillary serous carcinoma of the ovary. They are usually staged with the ovarian staging classification. Because the peritoneum is essentially always involved throughout the abdomen, the peritoneal tumors are usually within the Stage III (T3) or Staghe IV (M1) categories.

Pancreas (Endocrine): Resection 51P1 Pancreas (Endocrine) Tumor Staging Information (data derived from current specimen; in accord with the AJCC


Tumor size: A2 ____ x ____ x ____ cm

Histologic type: P2 Cannot be assessedP3 Pancreatic endocrine tumor, functional [specify type: _____ ] [correlation with clinical syndrome

and / or elevated serum levels of hormone product]P4 Pancreatic endocrine tumor, non-secretory P5 Pancreatic endocrine tumor, secretory status unknown

Extent of invasion: P16 Tumor limited to pancreasP17 Tumor invades beyond pancreatic capsule but does not invade other organsP18 Tumor extends directly to the [list: ___, ex. Duodenum, bile duct, stomach, spleen, colon,

adjacent large vessels (ex., portal vein, celiac artery, superior mesenteric vessels,common hepatic vessels.




Note: Margin review includes: posterior retroperitoneal surface of pancreas; distal pancreatic margin; common bile duct margin.


Perineural invasion: A29a Not identified[if applicable] A29b Present

Mitotic activity: P6 AbsentP8 Present, < 4 mitoses / high power fieldP9 Present, > 4 mitoses / high power field

Regional lymph nodes: F86 Cannot be assessedF87 No tumor involvement noted in ___ nodesF88 Tumor involvement noted in ___ of ___ nodes

Distant metastasis: P13 Cannot be assessedP14 No distant metastasisP15 Present, involving: (sites(s): ____________)

Additional findings: A13a None identifiedA13b [dictate list, example: acute or chronic pancreatitis; nesidioblastosis; other ____]

Pancreas (Exocrine & Neuroendocrine): Resection 35P10 Pancreas (Exocrine) Tumor Staging Information (data derived from current specimen; in accord with the AJCC


Tumor configuration: P37 Intraductal P39 Circumscribed, solidP38 Infiltrative P40 Circumscribed, cystic

Tumor size: A2 ____ x ____ x ____ cm

Histologic type: P11a Carcinoma in situP11b Ductal adenocarcinomaP11c Mixed ductal-endocrine carcinomaP11d Mucinous noncystic carcinomaP11e Serous cystadenocarcinomaP11f Mucinous cystadenocarcinomaP11g Intraductal papillary-mucinous carcinomaP11h Invasive papillary-mucinous carcinomaP11i Acinar cell carcinomaP11j Other, specify: _____

Histologic grade: A18 Not applicable [ductal carcinoma A18x GX: Cannot be assessed

only] A18a G1: Well differentiated ( > 95% gland forming)A18b G2: Moderately differentiated ( 50-95 % gland forming)A18c G3: Poorly differentiated (5-49 % gland forming)A18d G4: Undifferentiated ( < 5 % gland forming)

Extent of invasion: A20x pTX: Cannot be assessedA20 pT0: No evidence of primary tumor A20i pTis [Carcinoma in situ]A21 pT1 [Tumor limited to pancreas and < 2 cm in greatest dimension]A22 pT2 [Tumor limited to pancreas and > 2 cm in greatest dimension]A23 pT3 [Tumor extends beyond the pancreas but without involvement of the celiac axis or the

superior mesenteric artery; extension beyond the pancreas may include invasion of soft tissues adjacent to the pancreas, the extrapancreatic biliary system, and/or duodenum(including the ampulla of Vater).]

A24 pT4 [Tumor involves celiac axis or superior mesenteric artery (unresectable primary tumor)]

Regional lymph nodes: A6x pNX: Cannot be assessedA6 pN0: No tumor noted in _____ nodes

pN1: Regional lymph node metastasisA7a pN1a: Tumor present in ___ of ___ nodes. [Metastasis in a single lymph node.]A7b pN1b: Tumor present in ___ of ___ nodes. [Metastasis to multiple lymph nodes.]

[Note: Optimal exam includes a minimum of 12 lymph nodes. Anatomic identification of site of regional lymph nodes is not necessary unless separately submitted and identified by the surgeon.]





Note: Margin review includes: posterior retroperitoneal surface; distal pancreatic duct margin; common bile duct margin.



Additional findings: A13a None identifiedA13b [dictate list, example: acute or chronic pancreatitis; epithelial dysplasia; other ____]

Figure 1. The Head lies within the curve of the duodenum. TheUncinate process is a prolongation of the head that wraps behind the superior mesenteric artery and vein and comes to lie adjacent to the ascending part of the duodenum.

Figure 2. Posterior view of tumor arising in the pancreatic head, with dotted line indicating the location of the confluence of the portal and superior mesenteric veins. The hatched area shows the retroperitoneal (uncinate process) margin. The nonperitonealized surface of the uncinate process (uncinate margin) constitutes the retroperitoneal margin for pancreaticoduodenectomy specimens and should be inked; sections through the tumor at its closest approach to this margin should be submitted.

Multiple tumors: If more than 1 tumor is present in the pancreas, the tumor with the highest T category should be classified according to the pT definitions and either the multiplicity (“m”) or the actual number of simultaneous multiple tumors (eg, “3”) should be indicated in parentheses after the T category of the primary tumor (eg, pT3[m] or pT3[2]). This applies only to grossly recognizable, synchronous primary carcinomas and not to a single, grossly detected tumor with multiple separate microscopic foci.

Pancreatic Intraepithelial Neoplasia (PanIN): Noninvasive dysplastic lesions of the ductal epithelium often are found in the pancreatic parenchyma surrounding ductal adenocarcinoma. PanIN occurring at the resection margins of an otherwise completely resected malignancy should be noted in the pathology report. In this setting, the biologic significance of low-grade PanIN remains unclear, because these ductal changes may be seen in pancreata with benign lesions, but PanIN-3 is the equivalent of carcinoma in situ and should be reported as Tis. PanINs are thought to progress from flat to papillary lesions with increasing degrees of dysplasia. PanINs are believed to be the precursor lesions of ductal adenocarcinoma. Many of the cytological changes included in the PanIN spectrum are seen in cystic tumors of the pancreas, such as mucinous cystic neoplasms and papillary mucinous neoplasms, but PanINs, by definition, occur in nondilated ducts. PanINs have been classified at a National Cancer Institute Think Tank as follows:

Normal Nonmucinous flattened or cuboidal epithelium without dysplasiaPanIN-1A Flat mucinous epithelium without dysplasiaPanIN-1B Papillary mucinous epithelium without dysplasiaPanIN-2 Flat or papillary mucinous epithelium with mild-to-moderate dysplasia (mild-to-moderate nuclear

irregularity, hyperchromasia, and loss of polarity)

PanIN-3 Flat or papillary mucinous epithelium with severe dysplasia (marked nuclear irregularity, hyperchromasia, and loss of polarity), often with cribriforming and intraluminal blebbing (budding off of

noncohesive cells)

Pleural Mesothelioma: Resection [does not include tumors metastatic to the pleura]

65P50 Pleural Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 6th Ed.)

Histologic type: P51a Epithelioid mesotheliomaP51b Sarcomatoid mesotheliomaP51c Biphasic mesothelioma

P51d Desmoplastic mesothelioma Extent of invasion: A20x pTX: Cannot be assessed

A20 pT0: No evidence of primary tumorA21 pT1 [Tumor involves ipsilateral parietal pleura, with or without folcal involvement of

visceral pleura]A21a pT1a [Tumor involves ipsilateral parietal (mediastinal, diaphragmatic) pleura. No

involvement of the visceral pleura]A21b pT1b [Tumor involves ipsilateral parietalades (mediastinal, diaphragmatic) pleura, with

focal involvement of the visceral pleura]A22 pT2 [Tumor invades any of the ipsilateral pleural surfaces with involvement of any of the

following: confluent visceral pleural tumor (including fissure); diaphragmatic muscle; potentially lung parenchyma]resectable A23 pT3 [Tumor invades any of the ipsilateral pleural surfaces with involvement of any of the

following: endothoracic fascia; mediastinal fat; solitary focus of tumor invading the technically soft tissues of the chest wall; non-transmural involvement of the pericardium] unresectable A24 pT4 [Tumor invades any of the ipsilateral pleural surfaces with involvement of any of the

following: diffuse or multifocal invasion of soft tissues of the chest wall; any involvement of rib; invasion through the diaphragm to the peritoneum; invasion of any mediastinal organ (s); direct extension to the contralateral pleura; invasion into the spine; extension to the internal surface of the pericardium; pericardial effusion with positive cytology; invasion of the myocardium; invasion of the brachial plexus]

Regional lymph nodes: P72 pNX: Cannot be assessedP73 pN0: No tumor noted in ____ nodesP74 pN1: [Metastasis in ipsilateral peribronchial and / or ipsilateral hilar lymph nodes,

including intrapulmonary nodes involved by direct extension of primary tumor]P75 pN2: [Metastasis in ipsilateral internal mammary or mediastinal or subcarinal lymph node(s)]P76 pN3: [Metastasis in contralateral mediastinal, hilar, ipsilateral or internal mammary nodes,

Or in either ipsi- or contralateral scalene or supraclavicular lymph node(s)]




Note: Margin review includes: bronchial margin; pulmonary vascular margin; chest wall margin; mediastinal margins (including pericardium, great vessels, esophagus, trachea, vertebral body); diaphragm; extrapleural chest wall.



Additional findings: A13a None identifiedA13b [dictate list, example: feruginous bodies, pleural plaque; pulmonary interstitial fibrosis;

inflammation (type: _____ ); other ____]

Prostate: resection 9P77 Prostate Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 7th Ed.)

Histologic type: P78a Adenocarcinoma [conventional] P78g Basaloid and adenoid cystic carcinoma**

P78b Prostatic duct adenocarcinoma P78h Transitional cell carcinoma**

P78c Mucinous (colloid) adenocarcinoma P78i Small cell carcinomaP78d Signet ring cell carcinoma P78j Sarcomatoid carcinomaP78e Adenosquamous carcinoma P78k Lymphoepithelioma-like carcinoma**

P78f Squamous cell carcinoma** P78m Undifferentiated carcinoma, not otherwise specified**[this protocol does not apply to this tumor type]

Gleason score (primary pattern + secondary pattern): P79 ____ ( ____ + ____ ) [see note below for recent changes]

Histologic grade: A18x GX: Cannot be assessedA18a G1: Well differentiated [Gleason patterns 2-4]A18b G2: Moderately differentiated [Gleason patterns 5-6]A18k G3-4: Poorly differentiated/Undifferentiated [Gleason patterns 7-10]

Tumor quantitation: P80a ____ % prostatic tissue involved by carcinomaP80d ____ % blocks with tumor / total prostatic blocksP80e Tumor size ___ x ___ x ___ [if nodule visible on slide]

Extent of invasion: A20 pT0 [No tumor identified]A22 pT2 [Tumor confined within the prostate]A22a pT2a [Tumor involves one-half of one lobe or less]A22b pT2b [Tumor involves more than one-half of one lobe but not both lobes]A22c pT2c [Tumor involves both lobes]A23 pT3 [Extraprostatic extension (EPE); see EPE note below]A23a pT3a [Extraprostatic extension or microscopic invasion of bladder neck]A23b pT3b [Seminal vesicle invasion]A24 pT4 [Invasion of rectum, levator muscles and / or pelvic wall]


Size of largest nodal metastasis: B27 ____ cmExtranodal tumor extension: B28a No

B28b Yes

Distant metastasis: A10x pMX: Cannot be assessedA10 pM0: No distant metastasisA11 pM1: Present, involving: _____A11a pM1a: Present, involving: _____ [def.: tumor involves non-regional lymph nodes]A11b pM1b: Present, involving: _____ [def.: tumor involves bone]A11c pM1c: Present, involving: _____ [def.: other site(s), with or w/o bone disease]

Extraprostatic extension by tumor: P81a AbsentP81b Present [see Note below]


[Complete resection, no residual tumor left after resection]A28c ____ margin involved by extraprostatic extension ( __ mm diameter)A28d ____ margin involved by intraprostatic incision ( __ mm diameter)

Note: List all positive margins. Margin exam includes: apical margin; bladder neck margin; anterior margin; lateral margins; postero-lateral margins (neurovascular bundle); posterior margins.

Vascular/Lymphatic vessel invasion: B30x IndeterminateB30 Not identified

B30a Present

Seminal vesicle invasion: P82a AbsentP82b Present [Note: tumor in the adventitia of the seminal vesicle does not qualify;

Invasion of the muscular wall is required]Perineural invasion: P83a Absent

P83c Present within but not outside the prostateP83d Present within and outside the prostateP83e Present outside the prostate

Additional findings: A13a None identifiedA13b [list, ex. Radiation therapy effect noted; Hormonal therapy effect noted; prostatic intraepithelial

neoplasia (PIN); inflammation (type, ____); other ___ ]

Notes:

Gleason scoring: Pattern 1: single, separate, closely packed aciniPattern 2: single acini, more loosely arranged, less uniformPattern 3: single acini of variable size and separation, cribriform and papillary patternsPattern 4: irregular masses of acini and fused epithelium; can show clear cellsPattern 5: anaplastic carcinoma

If there is a minor secondary component (<5% of tumor) of higher grade, report both. Conversely, if a minor (<5% of tumor) secondary pattern is of lower grade, it need not be reported. For instance, where there is greater than 95% Gleason score 4 and less than 5% Gleason 3, the score should be reported as Gleason 8 (4 + 4).

There are differences between how needle core and how prostatectomy Gleason scores are reported: In needle biopsy specimens: If more than 2 patterns are present, and the worst grade is neither the predominant nor

the secondary grade, the predominant and highest grade should be chosen to arrive at a score (eg, 75% grade 3; 20%–25% grade 4; <5% grade 5 is scored as “3 + 5 = 8”).

In prostatectomies: If more than 2 patterns are present, and grade 5 is present as a tertiary pattern (not primary or secondary), its presence should be recognized in the report but not incorporated into the Gleason score. (eg, 75% grade 3; 20–25% grade 4; <5% grade 5 is scored as “3 + 4 = 7, with tertiary Gleason pattern 5”).

For radical prostatectomy specimens, Gleason score should be assigned to the dominant nodule(s), if present. Where more than one separate tumor is clearly identified, the Gleason scores of individual tumors can be recorded separately, or, at the very least, a Gleason score of the dominant or most significant lesion should be recorded. For instance, if there is a large Gleason score 4 (2 + 2) transition zone tumor and a separate, smaller Gleason score 8 (4 + 4), peripheral zone cancer, both scores should be reported, or, at the very least, the latter score should be reported rather than these scores being averaged.

Extraprostatic Extension (EPE): The specific location(s) and the number of sites (blocks) of EPE are useful to report. Descriptors of EPE (focal versus nonfocal) should be used. Focal EPE equates with only a few neoplastic glands being outside the prostate or a tumor involving less than 1 high-power field in 1 or 2 sections; nonfocal (established) EPE is more extensively spread beyond the prostatic edge. Positive surgical margins alone do not constitute EPE. You need one of the following:1. Tumor admixed with periprostatic fat.2. Tumor involving loose connective tissue in the plane of fat or beyond, even in the absence of direct contact between the tumor and the adipocytes. 3. Tumor involving perineural spaces in the periprostatic neurovascular bundles, even in the absence of fat involvement.4. In the apex, tumor admixed with skeletal muscle elements does not by itself constitute EPE. EPE is determined “when tumor extends beyond the confines of the normal glandular prostate.” Sometimes, there is a distinct bulging tumor nodule, which may be associated with a desmoplastic stromal reaction.

pTNM Descriptors (required only if applicable; select all that apply) Although they do not affect the stage grouping, they indicate cases needing separate analysis.

“m” suffix : pT(m)NM - indicates the presence of multiple primary tumors in a single site and is recorded in parentheses.“y” prefix : ypTNM - indicates cases performed during or following initial neoadjuvant chemotherapy, radiation therapy,

or both. The designation categorizes the extent of tumor present at the time of that examination and is not an estimate of tumor prior to neoadjuvant therapy.

“r” prefix : rTNM - indicates recurrent tumor staged after a documented disease-free interval.

Small Intestine: resection 39Q10 Small Intestinal Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 7th Ed.)Tumor size: A2 ____ x ____ x ____ cm

Histologic type: Q11a Cannot be determinedQ11b Adenocarcinoma in situ / severe dysplasiaQ11c AdenocarcinomaQ11d Mucinous adenocarcinoma (>50% mucinous)Q11e Signet ring cell carcinoma (>50% signet ring cells)Q11f Squamous cell carcinomaQ11g Adenosquamous carcinomaQ11h Small cell carcinomaQ11i Undifferentiated carcinomaQ11j [other; specify ___; ex., Medullary; Mixed carcinoid-adenocarcinoma ]

Histologic grade: A18 Not applicableA18x GX: Cannot be assessedA18a G1: Well differentiated ( > 95% gland forming)A18b G2: Moderately differentiated ( 50-95 % gland forming)A18c G3: Poorly differentiated (5-49 % gland forming)A18d G4: Undifferentiated ( < 5 % gland forming)

Extent of invasion: A20x pTX: Cannot be assessedA20 pT0: No evidence of primary tumorA20i pTis [Carcinoma in situ]A21a pT1a: [Tumor invades lamina propria, ie., intramucosal carcinoma. NOTE: This designation

differs from that for colon, in which tumor extension into the lamina propria is regarded as in situ carcinoma, because of the rich lymphatic network in small intestinal mucosa]

A21b pT1b: [Tumor invades submucosa]A22 pT2: [Tumor invades muscularis propriaA23 pT3: [Tumor invades through the muscularis propria into the subserosa or into the

mesentery or retroperitoneum with extension of 2 cm or less]A24a pT4a: [Tumor perforates the visceral peritoneum]A24b pT4b: [Tumor directly invades other organs or structures]

Regional lymph nodes: A6x pNX: Cannot be assessedA6 pN0: No tumor noted in ___ nodesA7 pN1: Tumor present in ___ of ___ nodes [1-3 positive nodes] A8 pN2: Tumor present in ___ of ___ nodes [4 or more positive nodes]

Distant metastasis: A10x pMX: Cannot be assessed A10 pM0: No distant metastasis A11 pM1: Present, involving: (sites(s):




Note: R0, R1 and R2 margins include examination of: Proximal and distal mucosal margins; Radial (deep) margin.



Additional findings: A13a None identified

A13b [list, ex. epithelial dysplasia; Crohn’s disease; celiac disease; adenomas; other ___

32 Q46 Stomach Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 7th Ed.)

Note: For tumors which arise in the proximal stomach < 5 cm of the EGJ and which cross the EGJ, use “Esophageal Staging form. Lymphomas, low-grade neuroendocrine tumors (carcinoid tumors), and sarcomas are also not included on this form.

Tumor size: A2 ____ x ____ x ____ cm

Tumor site: C2a____ ( [Note: Tumor location should be described in relation to the gastric region (cardia, including EGJ; fundus; corpus; antrum, pylorus), greater or lesser curvature, anterior or posterior wall.]

Histologic type: Q11a Cannot be determinedQ11b Adenocarcinoma in situ / severe dysplasiaQ11c Adenocarcinoma Q11c1 Adenocarcinoma, intestinal typeQ11c2 Adenocarcinoma, diffuse typeQ11d Mucinous adenocarcinoma (>50% mucinous)Q11e Signet ring cell carcinoma (>50% sig. ring cells)Q11f Squamous cell carcinomaQ11g Adenosquamous carcinomaQ11h Small cell carcinomaQ11i Undifferentiated carcinomaQ11j [other: specify ___ ]

Histologic grade: A18x GX: Cannot be assessedA18a G1: Well differentiated [if an adenocarcinoma, use >95% composed of glands]A18b G2: Moderately differentiated [if an adenocarcinoma, use 50-95% composed of glands]A18c G3: Poorly differentiated [if an adenocarcinoma, use <50% composed of glands]A18d G4: Undifferentiated

Extent of invasion: A20x pTX: Cannot be assessedA20 pT0: No evidence of primary tumorA20i pTis [Carcinoma in situ]A21 pT1 [Tumor invades lamina propria, muscularis mucosae or submucosa]A21a pT1a [Tumor invades lamina propria]A21b pT1b [Tumor invades submucosa]A22 pT2 [Tumor invades muscularis propria]A23 pT3 [Tumor penetrates subserosal connective tissue without invasion of visceral peritoneum

or adjacent structures]A24 pT4 [Tumor invades visceral peritoneum or adjacent structures]A24a pT4a [Tumor invades visceral peritoneum (serosa)]A24b pT4b [Tumor invades adjacent structures, not including duodenum or esophagus]

T1a T1b

Regional lymph nodes: A6x pNX: Cannot be assessedA6 pN0: No tumor noted in ___ nodesA7 pN1: Tumor present in ___ of ___ nodes [for cases with 1 to 2 + nodes]A8 pN2: Tumor present in ___ of ___ nodes [for cases with 3 to 6 + nodes]A9 pN3: Tumor present in ___ of ___ nodes [for cases with > 6 + nodes]A9a pN3a: Tumor present in ___ of ___ nodes [for cases with 7-15 + nodes]A9b pN3b: Tumor present in ___ of ___ nodes [for cases with >15 + nodes]

Distant metastasis: A10x pMX: Cannot be assessed A10 pM0: No distant metastasis A11 pM1: Present, involving: (sites(s): [includes + peritoneal cytology]




Note: R0, R1 and R2 margins include examination of: Proximal & distal margins; Mesenteric (radial) margin; any (+)margin.



Additional findings: A13a None identified A13b [list, ex. intestinal metaplasia; dysplasia; gastritis (type: ___ ); other ___ ]

69Testis: resection

Q20 Testicular Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 6th Ed.)

Serum hormone levels: Q21a UnknownQ21b Serum markers studies within normal limitsQ21c Alpha-fetoprotein (AFP) elevationQ21d Beta-subunit of human chorionic gonadotropin (beta-hCG) elevationQ21e Lactate dehydrogenase (LDH) elevation

Tumor size: A2 ____ x ____ x ____ cm

Tumor border configuration: C54 PushingC55 Infiltrating

Histologic type: Q22 Cannot be determined [Germ cell tumors]

Q23 Intratubular germ cell neoplasm, unclassifiedQ24 SeminomaQ24a Seminoma with syncytiotrophoblastic cellsQ24b Spermatocytic seminomaQ24c Spermatocytic seminoma with a sarcomatous componentQ25 Embryonal carcinomaQ26 Yolk sac tumorQ27 ChoriocarcinomaQ27a Choriocarcinoma, “monophasic type”Q28 Placental site trophoblastic tumorQ29 TeratomaQ29a Teratoma, matureQ29b Teratoma, immatureQ29c Teratoma, with a secondary malignant componentQ29d Teratoma, monodermal variant: CarcinoidQ29e Teratoma, monodermal variant: Primitive neuroectodermal tumorQ30 Mixed germ cell tumor [list components and their percentages]Q31 PolyembryomaQ32 Diffuse embryoma

[Sex cord-stromal tumors]Q33 Leydig cell tumorQ34 Sertoli cell tumorQ34a Large cell calcifying Sertoli cell tumorQ34b Sclerosing Sertoli cell tumorQ35 Granulosa cell tumorQ35a Granulosa cell tumor, adult typeQ35b Granulosa cell tumor, juvenile typeQ36 Mixed and indeterminate (unclassified) sex cord stromal tumor

[Mixed germ cell-sex cord-stromal tumors]Q37 Gonadoblastoma

[Other]Q38 Other, specify: ____

Extent of invasion: A20x pTX: Cannot be assessedA20 pT0: No evidence of primary tumorA20i pTis [Intratubular germ cell neoplasm (carcinoma in situ)]A21 pT1 [Tumor limited to the testis and epididymis without vascular/lymphatic

invasion (tumor may invade tunica albuginea but not the tunica vaginalis)]A22 pT2 [Tumor limited to the testis and epididymis with vascular/lymphatic

invasion or tumor extending through tunica albuginea with involvement oftunica vaginalis]

A23 pT3 [Tumor invades spermatic cord with or without vascular/lymphatic invasion]

A24 pT4 [Tumor invades scrotum with or without vascular/lymphatic invasion]

70Regional lymph nodes: A6x pNX: Cannot be assessed

A6 pN0: No tumor noted in ___ nodesA7 pN1: Tumor present in ___ of ___ nodes [def.: Metastasis, with a lymph node mass < 2 cm

in greatest dimension and 5 or fewer positive nodes, none > 2 cm in greatest dimension]

A8 pN2: Tumor present in ___ of ___ nodes [def.: Metastasis, with a lymph node mass > 2 cm but < 5 cm in greatest dimension, or more than 5 nodes positive, none > 5 cm; or evidence of extranodal extension of tumor]

A9 pN3: Tumor present in ___ of ___ nodes [def.: Metastasis with a lymph node mass > 5 cm in greatest dimension]

Distant metastasis: A10x pMX: Cannot be assessedA10 pM0: No distant metastasisA11 pM1: Present, involving: _____A11a pM1a: Present, involving: ___ [Non-regional lymph node or pulmonary metastasis]A11b pM1b: Present, involving: ___ [Distant mets other than to non-regional lymph nodes or lungs]





Histologic type of metastatic tumor: R37 [specify]

Serum tumor markers: Q40x SX: Serum marker studies not available or performed[if known] Q40 S0: Serum marker study levels within normal limits

Q41 S1 [LDH < 1.5 x nl, & HCG < 5000 mIU/ml, & AFP < 1000 ng/ml]Q42 S2 [LDH 1.5 - 10 x nl, or HCG 5000 – 50,000 mIU/ml, or AFP 1000 – 10,000 ng/ml]Q43 S3 [LDH > 10 x nl; HCG > 50,000 mIU/ml; AFP > 10,000 ng/ml]

Additional findings: A13a None identifiedA13b [dictate list, example: inflammation (type: ____ ); Leydig cell hyperplasia; scarring;

hemosiderin-laden macrophages; intratubular calcification; atrophy; other ____]

50T1 Thyroid Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 7th Ed.)

Tumor size: A2 ____ x ____ x ____ cm [Note: If multiple foci of carcinoma are present, give details on the largest 2 foci and note the others in the section on Additional Pathological Findings. The “m” suffix indicates the presence of multiple primary tumors in a single site and isrecorded in parentheses: pT(m)NM.]

Histologic type: T2a Follicular carcinoma, ___ [add one of the following variants, if warranted:Clear cell variant Oncocytic variant

T2b Papillary carcinoma, ___ [add one of the following variants:Classical type Macrofollicular variantClear cell variant Microcarcinoma [see Notes below]Columnar cell variant Oncocytic or oxyphyllic variant (can be pap or follicular var)Diffuse sclerosing variant Solid variantFollicular variant Tall cell variantWarthin-like variant]

T2c Medullary carcinomaT2d Undifferentiated (anaplastic) carcinomaT2e [other, specify: ____ ex. Poorly differentiated thyroid carcinomas including insular carcinoma]

Extent of invasion: A20x pTX: Cannot be assessedA20 pT0: No evidence of primary tumorA21a pT1a [Tumor size < 1 cm, limited to the thyroid]A21b pT1b [Tumor >1 and < 2 cm, limited to the thyroid]A22 pT2 [Tumor > 2 cm and < 4 cm, limited to the thyroid]A23 pT3 [Tumor > 4 cm, limited to the thyroid,

OR any tumor with minimal extrathyroid extension (e.g., extension to sternothyroid muscle or perithyroid soft tissues]

A24a pT4a [Tumor of any size extending beyond the thyroid capsule to invade subcutaneous soft tissues, larynx, trachea, esophagus, or recurrent laryngeal nerve

OR any Intrathyroid anaplastic carcinoma (ie., surgically resectable)]A24b pT4b [Tumor invades prevertebral fascia or encases carotid artery or mediastinal vessels

OR any Extrathyroid anaplastic carcinoma (ie., surgically nonresectable)]

Regional lymph nodes: A6x pNX: Cannot be assessedA6 pN0: No tumor noted in ___ of ___ nodesA7a pN1a: Tumor present in ___ of ___ nodes [metastasis to Level VI - pretracheal, paratracheal or

Prelaryngeal/Delphian nodes]A7b pN1b: Tumor present in ___ of ___ nodes [metastasis to unilateral, bilateral or contralateral

cervical (Levels I, II, III, IV, V) or retropharyngeal or sup.mediastinal nodes (Level VII)]Extranodal tumor extension:

B28a NoB28b Yes

Distant metastasis: A10x pMX: Cannot be assessedA10 pM0: No distant metastasisA11 pM1: Present, involving ___




Tumor capsule: A3x Cannot be assessed [See Notes below]A3a Totally encapsulatedA3b Partially encapsulatedA3c None

Tumor capsular invasion: A4x Cannot be assessed A4a Not identified

A4b Present, minimalA4c Present, extensive

Vascular/Lymphatic vessel invasion: B30x Indeterminate [See Notes below]B30 Not identifiedB30b Present, focal (less than 4 vessels)B30c Present, extensive (4 or more vessels)

Extrathyroidal extension: Axxx Cannot be assessed [See Notes below]Axxx Not identifiedAxxx Present, minimalAxxx Present, extensive

Additional findings: A13a None identifiedA13b [dictate list, example: nodular goiter; adenoma; thyroiditis; other ____]

Notes: Papillary microcarcinoma (AKA occult papillary ca) refers to tumors found incidentally and measuring 1 cm or less. In spite of their rather common identification in thyroid gland resections and apparent indolent biologic behavior, CAP recommends issuing a staging form for all papillary thyroid carcinoma, including subcentimeter tumors.

Extrathyroidal Extension: Minimal extrathyroidal extension: the presence of carcinoma extending into perithyroidal tissues, including

infiltration of adipose tissue and skeletal muscle, as well as around (and into) sizable vascular structures and nerves. Extension into adipose tissue and/or skeletal muscle can be problematic given the fact that both can be found within the thyroid gland proper under normal conditions. If present, a desmoplastic response may be a helpful finding in thedetermination of extrathyroidal extension. The identification of thick-walled vessels and/or small peripheral nerves in association with adipose tissue may be of greater assistance as these structures are not located in the thyroid gland proper and their presence would be helpful in determining whether the carcinoma is extrathyroidal in extent.

Extensive extrathyroidal extension: usually established clinically by documentation of carcinoma well beyond the thyroid gland with direct invasion (ie, not metastasis) into one or more of the following structures: - subcutaneous soft tissues; - adjacent viscera, including the larynx, trachea and/or esophagus; - the recurrent laryngeal nerve, carotid artery or mediastinal blood vessels.

Figure 1. Vascular invasion (VI): depicts a follicular neoplasm (green) surrounded by a fibrous capsule (blue). A: Bulging of tumor into vessels within the tumor proper does not constitute VI. B: Tumor thrombus covered by endothelial cells in intracapsular vessel qualifies as VI. C: Tumor thrombus in intracapsular vessel considered as VI since it is attached to the vessel wall. D: Although not endothelialized, this tumor thrombus qualifies for VI because it is accompanied by a fibrin thrombus. E: Endothelialized tumor thrombus in vessel outside the tumor capsule represents VI. F: Artefactual dislodgement of tumor manifesting as irregular tumor fragments into vascular lumen unaccompanied by

endothelial covering or fibrin thrombus.

Figure 2: Capsular invasion (CI): depicts a follicular neoplasm (orange) surrounded by a fibrous capsule (green). A: Bosselation on the inner aspect of the capsule

does not represent CI;B: Sharp tumor bud invades into but not through the

capsule suggesting invasion requires deeper sections to exclude CI;

C: tumor totally transgresses the capsule invading beyond the outer contour of the capsule qualifies as CI;

D: tumor clothed by thin (probably new) fibrous capsule but already extending beyond an imaginary (dotted) line drawn through the outer contour of the capsule qualifies as CI;

E: satellite tumor nodule with similar features (architecture, cytomorph) to the main tumorlying outside the capsule qualifies as CI;

F: Follicles aligned perpendicular to the capsule suggesting invasion requiring deeper sections to exclude CI

G: Follicles aligned parallel to the capsule do not represent CI;

H: mushroom-shaped tumor with total transgression of the capsule qualifies as CI; I: mushroom-shaped tumor within but not through

the capsule suggests invasion requiring deeper sections to exclude CI; J: neoplastic follicles in the fibrous capsule with a degenerated appearance accompanied by lymphocytes and

siderophages does not represent CI but rather capsular rupture related to prior fine needle aspiration.

Trophoblast: resection 27T21 Gestational Trophoblast Tumor (GTT) Staging Information (data derived from current specimen; in accord with the

AJCC Cancer Staging Manual, 6th Ed.)


62Upper aerodigestive tract: resectionU1 Upper Respiratory Tract Tumor Staging Information (data derived from current specimen; in accord with the AJCC

Cancer Staging Manual, 6th Ed.)U2 Upper Digestive Tract Tumor Staging Information (data derived from current specimen; in accord with the AJCC


Histologic type: U3a Squamous cell carcinoma U3L Clear cell carcinomaU3b Verrucous squamous cell carcinoma U3m Adenosquamous carcinomaU3c Spindle cell carcinoma U3p Giant cell carcinomaU3d Adenoid squamous cell carcinoma U3q Salivary duct carcinomaU3e Basaloid squamous cell carcinoma U3r Carcinoid tumorU3f Adenocarcinoma U3s Atypical carcinoid tumorU3g Acinic cell carcinoma U3t Small cell carcinomaU3h Mucoepidermoid carcinoma U3u Lymphoepithelial carcinomaU3i Adenoid cystic carcinoma U3w Undifferentiated carcinomaU3j Carcinoma in pleomorphic adenoma U3x [other, specify: ____ ]U3k Epithelial-myoepithelial carcinoma

Histologic grade: A18x GX: Cannot be assessed A18a G1: Well differentiated


Extent of invasion:Applies to all: A20x pTX: Cannot be assessed

A20 pT0: No evidence of primary tumorA20i pTis [Carcinoma in situ]

Lip and Oral Cavity: A21 pT1 [Tumor < 2 cm in greatest dimension]A22 pT2 [Tumor > 2 cm but < 4 cm in greatest dimension]A23 pT3 [Tumor > 4 cm in greatest dimension]

For lip: A24 pT4 [Tumor invades through cortical bone, inferior alveolar nerve, floorof mouth, skin of face (e.g., chin or nose)]

For oral cavity: A24a pT4a [Tumor invades adjacent structures, such as through cortical bone, into deep(extrinsic) muscle of tongue, maxillary sinus, skin (potentially resectable)]

A24b pT4b [Tumor invades masticator space, pterygoid plates, or skull base and / or encases internal carotid artery (unresectable)]

Nasopharynx: A21 pT1 [Tumor confined to nasopharynx]A22 pT2 [Tumor extends to soft tissue of oropharynx and / or nasal fossa]A22a pT2a [Tumor extends to soft tissue of oropharynx and / or nasal fossa,

without parapharyngeal extension]A22b pT2b [Tumor extends to soft tissue of oropharynx and / or nasal fossa, with

parapharyngeal extension]A23 pT3 [Tumor invades bony structures and / or paranasal sinuses]A24 pT4 [Tumor with intracranial extension and / or involvement of cranial nerves,

infratemporal fossa, hypopharynx or orbit]

Oropharynx: A21 pT1 [Tumor < 2 cm in greatest dimension]A22 pT2 [Tumor > 2 but < 4 cm in greatest dimension]A23 pT3 [Tumor > 4 cm in greatest dimension]A24a pT4a [Tumor invades the larynx, deep/extrinsic muscle of tongue, medial

pterygoid, hard palate, or mandible (potentially resectable)]A24b pT4b [Tumor invades lateral pterygoid muscle, pterygoid plates, lateral

nasopharynx, or skull base or encases carotid artery (unresectable)]

Hypopharynx: A21 pT1 [Tumor limited to 1 subsite of hypopharynx and <2cm in greatest dimension]A22 pT2 [Tumor invades more than one subsite of hypopharynx or an adjacent site,

or measures > 2 cm but < 4 cm in greatest dimension, without fixation of hemilarynx]

A23 pT3 [Tumor measures > 4 cm in greatest dimension, or with fixation of hemilarynx]

A24a pT4a [Tumor invades thyroid/cricoid cartilage, hyoid bone, throid gland, 63esophagus or central compartment soft tissue (potentially resectable)]

A24b pT4b [Tumor invades prevertegral fascia, encases carotid artery, or involves mediastinal structures (unresectable)]

Supraglottis: A21 pT1 [Tumor limited to 1 subsite of supraglottis with normal vocal cord mobility]A22 pT2 [Tumor invades mucosa of more than one adjacent subsite of supraglottis

or glottis or region outside the supraglottis (ie., mucosa of base of tongue, vallecula, medial wall of piriform sinus) without fixation of the larynx]

A23 pT3 [Tumor limited to larynx with vocal cord fixation and/or invades any of the following: postcricoid area, pre-epiglottic tissues, deep base of tongue]

A24a pT4a [Tumor invades through thyroid cartilage, and / or extends into the soft tissues beyond the larynx (eg, trachea, soft tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus) (potentially resectable)]

A24b pT4b [Tumor invades prevertebral prevertebral space, encases carotid artery, or invades mediastinal structures (unresectable)]

Glottis: A21 pT1 [Tumor limited to vocal cord(s) (may involve anterior or posterior commissure) with normal mobility]

A21a pT1a [Tumor limited to one vocal cord with normal mobility]A21b pT1b [Tumor involves both vocal cords with normal mobility]A22 pT2 [Tumor extends to supraglottis and / or subglottis, and / or with impaired

vocal cord mobility]A23 pT3 [Tumor limited to larynx with vocal cord fixation]A24a pT4a [Tumor invades through thyroid cartilage and / or extends to other tissues

beyond the larynx (trachea, soft tissues of neck, thyroid, pharynx) (potentially resectable)]


Subglottis: A21 pT1 [Tumor limited to subglottis]A22 pT2 [Tumor extends to vocal cord(s) with normal or impaired mobility]A23 pT3 [Tumor limited to larynx with vocal cord fixation]A24a pT4a [Tumor invades through cricoid or thyroid cartilage and / or extends into

other tissues beyond the larynx (trachea, soft tissues of neck, thyroid, esophagus (potentially resectable)]


Maxillary sinus: A21 pT1 [Tumor limited to the sinus mucosa with no erosion or destruction of bone]

A22 pT2 [Tumor causing bone erosion or destruction, except for the posterior antral wall, including extension into hard palate and / or middle nasal meatus]

A23 pT3 [Tumor invades any of the following: bone of posterior wall of maxillary sinus, subcutaneous tissues, skin of cheek, floor or medial wall of orbit, infratemporal fossa, pterygoid plates, ethmoid sinuses]

A24a pT4a [Tumor invades anterior orbital contents, skin of cheek, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid or frontal sinuses (potentially resectable)]

A24b pT4b [Tumor invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than maxillary division of trigeminal nerve V2, nasopharynx, or clivus (unresectable)]

Nasal cavities & Ethmoid sinus: A21 pT1 [Tumor confined to any one subsite with or without bone erosion]

A22 pT2 [Tumor invading two subsites in a single region or extending to involve an adjacent region within the nasoethmoidal complex, with or without bony invasion]

A23 pT3 [Tumor extends to invade the medial wall or floor of the orbit, maxillary sinus, palate, or cribriform plate]

A24a pT4a [Tumor invades any of the following: anterior orbital contents, skin of nose or cheek, minimal extension to anterior cranial fossa, pterygoid plates, sphenoid or frontal sinuses (potentially resectable)]

A24b pT4b [Tumor invades any of the following: orbital apex, dura brain, middle

64 cranial fossa, cranial nerves other than maxillary division of trigeminal nerve V2, nasopharynx, or clivus (unresectable)]

Salivary glands: A21 pT1 [Tumor < 2 cm in greatest dimension without extraparenchymal extension*]A22 pT2 [Tumor > 2 cm but < 4 cm in greatest dimension without extraparenchymal

extension*][*Extraparenchymal extension A23 pT3 [Tumor > 4 cm and / or with extraparenchymal extension*]is clinical or macroscopic A24a pT4a [Tumor invades skin, mandible, ear canal, and/or facial nerve (potentially extension and does not include resectable)]microscopic extension alone] A24b pT4b [Tumor invades skull base and / or pterygoid plates and / or encases carotid

artery (unresectable)]Regional lymph nodes: All sites: A6x pNX: Cannot be assessed

A6 pN0: No tumor noted in ___ nodes

All sites, exceptNasopharynx: A7 pN1: Tumor present in ___ of ___ nodes [Metastasis to a single ipsilateral node, < 3 cm in

greatest dimension]A8 pN2: Tumor present in ___ of ___ nodes [Metastasis to a single ipsilateral node > 3 cm but

< 6 cm in greatest dimension; or in multiple ipsilateral lymph nodes, none > 6 cm in greatest dimension; or in bilateral or contralateral nodes, none > 6 cm in greatest dimension]

A8a pN2a: Tumor present in ___ of ___ nodes [Metastasis in a single ipsilateral node, > 3 cm but < 6 cm in greatest dimension]

A8b pN2b: Tumor present in ___ of ___ nodes [Metastasis in multiple ipsilateral nodes, none > 6 cm in greatest dimension]

A8c pN2c: Tumor present in ___ of ___ nodes [Metastasis in bilateral or contralateral lymph nodes, none > 6 cm in greatest dimension]

A9 pN3: Tumor present in ___ of ___ nodes [Metastasis in a lymph node > 6 cm in greatest dimension]

Nasopharynx: A7 pN1: Tumor present in ___ of ___ nodes [Unilateral metastasis in lymph node(s) > 6 cm in greatest dimension, above supraclavicular fossa]

A8 pN2: Tumor present in ___ of ___ nodes [Bilateral metastasis in lymph node(s) > 6 cm in greatest dimension, above supraclavicular fossa]

A9 pN3: Tumor present in ___ of ___ nodes [Metastasis in a lymph node > 6 cm in greatest dimension and / or to supraclavicular fossa]

A9a pN3a: Tumor present in ___ of ___ nodes [Metastasis in a lymph node > 6 cm in greatest dimension]

A9b pN3b: Tumor present in ___ of ___ nodes [Tumor present in supraclavicular nodes]






Additional findings: A13a None identifiedA13b [dictate list, example: inflammation (specify type); epithelial hyperplasia; epithelial dysplasia;

implantation site; other ____ ]

R45 Bladder Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 7th Ed.)

Tumor size: A2 ____ x ____ x ____ cm

Histologic type: R48a Cannot be determinedR48b Urothelial (transitional cell) papillomaR48c Urothelial (transitional cell) papilloma, inverted typeR48d Papillary urothelial (transitional cell) neoplasm, low malignant potentialR48e Urothelial (transitional cell) carcinoma in situR48f Urothelial (transitional cell) carcinoma R48g Urothelial (transitional cell) carcinoma, with squamous differentiationR48h Urothelial (transitional cell) carcinoma, with glandular differentiationR48i Urothelial (transitional cell) carcinoma, with squamous and glandular differentiationR48j Squamous cell carcinomaR48k AdenocarcinomaR48L Undifferentiated carcinomaR48m Small cell carcinomaR48p [other, specify: ____ ]

Histologic grade: A18x GX: Cannot be assessed(urothelial lesions) A18s Low grade

A18t High grade

Histologic grade: A18x GX: Cannot be assessed(adenoca & SCC) A18a G1: Well differentiated

A18b G2: Moderately differentiatedA18c G3: Poorly differentiated

Extent of invasion: A20x pTX: Cannot be assessedA20 pT0: No evidence of primary tumorA20a pTa [Non-invasive papillary ca]A20i pTis [“flat” Carcinoma in situ]A21 pT1 [Tumor invades lamina propria]A22 pT2 [Tumor invades muscularis propria]A22a pT2a [Tumor invades superficial

muscularis propria (inner half)]A22b pT2b [Tumor invades deep muscularis propria (outer half)]A23 pT3 [Tumor invades perivesical tissue]A23a pT3a [Tumor microscopically invades perivesical tissue]A23b pT3b [Tumor macroscopically invades perivesical tissue (extravesicular mass)]A24 pT4 [Invades any of the following: prostate, uterus, vagina, pelvic wall, abdominal wall]A24a pT4a [Tumor invades prostate or uterus or vagina]A24b pT4b [Tumor invades pelvic wall or abdominal wall]

Regional lymph nodes: A6x pNX: Cannot be assessed (see Notes below)A6 pN0: No tumor noted in ___ nodesA7 pN1: Tumor present in ___ of ___ nodes [Metastasis to single node in the true pelvis]A8 pN2: Tumor present in ___ of ___ nodes [Metastasis to multiple nodes in the true pelvis] A9 pN3: Tumor present in ___ of ___ nodes [Metastasis to at least common iliac (ie., extrapelvic) node]





Note: Margin review includes: deep radial margin (soft tissue); ureteral margin; urethral margin; urachal margin (if applicable); uterine margin (if applicable); vaginal margin (if applicable)

59


Additional findings: A13a None identifiedA13b [dictate list, example: inflammation (type: ____ ); ulceration; hyperplasia; dysplasia (focal or

multifocal); other ____ ]

Notes:

Lymph Nodes: Adequate nodal staging requires removal of the primary nodal regions (external iliac, hypogastric and obturator nodes). Excision of the primary nodal regions should result in an average of > 12 lymph nodes. The National Cancer Database revealed the survival breakpoint for bladder tumor was finding 4 nodes.

World Health Organization (WHO) 2004/ International Society of Urologic Pathology (ISUP) Consensus Classification for Urothelial (Transitional Cell) Lesions

Normal#Hyperplasia

Flat hyperplasiaPapillary hyperplasia

Flat Lesions with AtypiaReactive (inflammatory) atypiaAtypia of unknown significanceDysplasia (low-grade intraurothelial neoplasia)#

Carcinoma in situ (high-grade intraurothelial neoplasia)##

Papillary NeoplasmsPapillomaInverted papillomaPapillary neoplasm of low malignant potentialPapillary carcinoma, low-gradePapillary carcinoma, high-grade###

Invasive NeoplasmsLamina propria invasionMuscularis propria (detrusor muscle) invasion

# May include cases formerly diagnosed as “mild dysplasia.”## Includes cases with “severe dysplasia.”### Option exists to add comment as to the presence of marked anaplasia.

Variants of Invasive urothelial carcinoma include: Deceptively bland variants: Nested pattern (resembling von Brunn’s nests)

Small tubular patternMicrocystic patternInverted pattern

Squamous differentiationGlandular differentiationMicropapillarySarcomatoidVariants with unusual cytoplasmic features: Clear cell (glycogen rich)

PlasmacytoidRhabdoidLipoid rich

Urothelial carcinoma with syncytiotrophoblastsUnusual stromal reactions: Pseudosarcomatous stroma / Stromal osseous or cartilaginous metaplasia

/ Osteoclast-type giant cells / with prominent lymphoid infiltrate

60

R47 Renal Pelvis Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 7th Ed.)

Tumor size: A2 ____ x ____ x ____ cm

Tumor configuration: R87 PapillaryR88 SolidR89 Indeterminate



A18t High grade

Histologic grade: A18x GX: Cannot be assessed(adenoca & SCC) A18a G1: Well differentiated


Extent of invasion: A20x pTX: Cannot be assessedA20 pT0: No evidence of primary tumorA20a pTa [Non-invasive papillary carcinoma]A20i pTis [Carcinoma in situ] (“flat tumor”)A21 pT1 [Tumor invades lamina propria]A22 pT2 [Tumor invades muscularis propria]A23 pT3 [Tumor invades peripelvic fat or the renal parenchyma]A24 pT4 [Tumor invades adjacent organs, or through the kidney into the perinephric fat]

Regional lymph nodes:A6x pNX: Cannot be assessedA6 pN0: No tumor noted in ___ nodesA7 pN1: Tumor present in ___ of ___ nodes [Metastasis to a single node, < 2 cm in greatest dimension]

A8 pN2: Tumor present in ___ of ___ nodes [Metastasis to a single node > 2cm and < 5 cm diameter, OR mets to multiple nodes, all of which are < 5 cm in greatest dimension]

A9 pN3: Tumor present in ___ of ___ nodes [Metastasis to at least one node which is > 5 cm in greatest dimension]




Note: Margin review includes: deep radial hilar margin (soft tissue); ureteral margin; renal parenchymal margin.




55

R46 Ureteral Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 7th Ed.)

Tumor size: A2 ____ x ____ x ____ cm

Tumor configuration: R87 PapillaryR88 SolidR89 Indeterminate



A18t High grade

Histologic grade: A18x GX: Cannot be assessed( adenoca & SCC) A18a G1: Well differentiated


Extent of invasion: A20x pTX: Cannot be assessedA20 pT0: No evidence of primary tumorA20a pTa [Non-invasive papillary carcinoma]A20i pTis [Carcinoma in situ] (“flat tumor”)A21 pT1 [Tumor invades subepithelial connective tissue]A22 pT2 [Tumor invades muscle]A23 pT3 [Tumor invades beyond muscularis into periureteric fat]A24 pT4 [Tumor invades adjacent organs, or through the kidney into the perinephric fat]


A8 pN2: Tumor present in ___ of ___ nodes [Metastasis to a single node > 2cm and < 5 cm diameter, OR mets to multiple nodes, all of which are < 5 cm in greatest dimension]

A9 pN3: Tumor present in ___ of ___ nodes [Metastasis to at least one node which is > 5 cm in greatest dimension]





Note: Margin review includes: deep radial periureteral soft tissue margin; proximal ureteral margin; distal ureteral margin; renal pelvic margin.



57

R46a Urethral Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 7th Ed.)

Tumor size: A2 ____ x ____ x ____ cm



A18t High grade

Histologic grade: A18x GX: Cannot be assessed( adenoca & SCC) A18a G1: Well differentiated


Extent of invasion: A20x pTX: Cannot be assessedA20 pT0: No evidence of primary tumorA20a pTa [Non-invasive papillary polypoid or verrucous carcinoma]A20u pTis pu [Carcinoma in situ, involvement of prostatic urethra]A20d pTis pd [Carcinoma in situ, involvement of prostatic ducts]A21 pT1 [Tumor invades subepithelial connective tissue – only for invasion from urethral lumen;

tumors invading directly from prostatic ducts are at least pT2]A22 pT2 [Tumor invades any of: prostatic stroma, corpus spongiosum, periurethral muscle]A23 pT3 [Tumor invades any of: corpus cavernosum, beyond prostatic capsule, or bladder neck]A24 pT4 [Tumor invades adjacent organs, such as invasion of bladder]


A8 pN2: Tumor present in ___ of ___ nodes [Metastasis to a single node > 2cm, OR mets to multiple nodes]





Note: Margin review includes: deep radial periureteral soft tissue margin; proximal ureteral margin; distal ureteral margin; renal pelvic margin.




12Uterine Cervix: Hysterectomy/ Pelvic Exenteration

X1 Cervical Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 7th Ed.)

Tumor site: X2a Right superior quadrant X2c Left superior quadrantX2b Right inferior quadrant X2d Left inferior quadrant

Histologic type:X3a Mild dysplasia (CIN 1/LSIL) X6 AdenocarcinomaX3b Moderate dysplasia (CIN 2/HSIL) X6a Endometrioid adenocarcinomaX3c Severe dysplasia (CIN 3/HSIL) X6b Clear cell adenocarcinomaX3d Carcinoma in situ (CIN 3/HSIL) X6c Mucinous adenocarcinoma

X4 Squamous cell carcinoma X7 Adenosquamous carcinomaX4a Squamous cell carcinoma, keratinizing subtype X8 Small cell carcinomaX4b Squamous cell carcinoma, non-keratinizing subtypeX4c Squamous cell carcinoma, verrucous subtype X9 (other, specify: ____ )

X5 Glandular intraepithelial dysplasiaX5a Adenocarcinoma in situ


Stromal invasion: X9a ___ mm in depth ; ___ mm horizontal spread [Note: Only include this if the lesion is invasive. The depth of invasion is measured from the base of the epithelial-stromal junction,

eithersurface or glandular, of the most superficial epithelial papilla adjacent to the origin of the tumor, to the deepest point of invasion. Vascular involvement does not alter the staging.]

TNM (FIGO): F9x pTX(--): Cannot be assessedF9 pT0 (--) [No evidence of primary tumor]F9i pTis (--) [Carcinoma in situ]F11 pT1 (I) [Confined to uterus]F11a pT1a (IA) [Invasive carcinoma diagnosed by microscopy only; not grossly visual]

Note: if tumor also F11a1 pT1a1 (IA1) [Stromal invasion < 3.0 mm in depth; horizontal spread < 7.0 mm has a metastasis, F11a2 pT1a2 (IA2) [Stromal invasion > 3.0 mm but < 5.0 mm in depth; horizontal change the FIGO spread < 7.0 mm] stage to IVB, F11b pT1b (IB) [Clinically visible lesion confined to the cervix; whatever the TNM OR microscopic lesion > 5.0 mm in depth or >7.0 mm horizontal spread] stage is. F11b1 pT1b1 (IB1) [Clinically visible lesion < 4.0 cm in greatest dimension]

F11b2 pT1b2 (IB2) [Clinically visible lesion > 4.0 cm in greatest dimension]F12 pT2 (II) [Tumor invades beyond uterus but not to pelvic wall or to lower 1/3 of vagina]F12a pT2a (IIA) [Tumor without parametrial invasion]F12a1 pT2a1 (IIA1) [Clinically visible lesion < 4.0 cm in greatest dimension]F12a2 pT2a2 (IIA2) [Clinically visible lesion > 4.0 cm in greatest dimension]F12b pT2b (IIB) [Tumor with parametrial invasion]F13 pT3 (III) [Tumor extends to the pelvic wall and / or involves the lower third of the

vagina and / or causes hydronephrosis or nonfunctioning kidney]F13a pT3a (IIIA) [Tumor involves lower third of vagina, but not to pelvic wall]F13b pT3b (IIIB) [Tumor extends to pelvic wall and / or causes hydronephrosis or

nonfunctioning kidney]F14 pT4 (IVA): [Tumor invades the mucosa of bladder or rectum and /or extends beyond the

true pelvis]

Regional lymph nodes: A6x pNX: Cannot be assessedA6 pN0: No tumor noted in ___ nodes

A7 pN1: Tumor present in ___ of ___ nodes (Note: 6 or more nodes is optimal)

13Distant metastasis: A10x pMX: Cannot be assessed

A10 pM0: No distant metastasisA11f pM1 (FIGO IVB): Present, involving: ____





Additional findings: A13a None identifiedA13b [dictate list, example: koilocytosis; inflammation (type: ____ ); microorganisms present

(specify: ____ ); other ____ Note: your reportshould state what organs are involved by direct extension and / or by metastasis, including assessments of : Uterine cervix

Uterine corpusVaginaVulvaFallopian tubesOvariesBladderRectum

If an independent primary tumor present, use a second section with the appropriate staging information

14

Blank

Vagina: resection 23X50 Vaginal Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 7th Ed.)

Tumor site: X51a Upper third [for the tumor site, also identify if it is: circumferential,X51b Middle third anterior, posterior, left lateral or right lateral. X51c Lower third Ex., Tumor site: Upper third, circumferential ]X51d Unknown

Tumor size: A2 ____ x ____ x ____ cm

Histologic type: X4 Squamous cell carcinomaX6 AdenocarcinomaX7 Adenosquamous carcinomaX9 (other, specify: ____ )


TNM (FIGO): F9x pTX (--): Cannot be assessed F9 pT0 (--) [No evidence of primary tumor]

Note: if tumor also has a F9i pTis (0) [Carcinoma in situ] metastasis, change the F11 pT1 (I) [Tumor confined to vagina] FIGO stage to IVB, F12 pT2 (II) [Tumor invades paravaginal tissues but not to pelvic wall] whatever the TNM F13 pT3 (III) [Tumor extends to pelvic wall] stage is. F14 pT4 (IVA) [Tumor invades bladder mucosa or rectum, and / or extends beyond true

pelvis]Regional lymph nodes: A6x NX: Cannot be assessed

A6 N0: No tumor noted in ____ nodesA7 N1: Tumor present in ___ of ___ [pelvic or inguinal] lymph nodes






Additional findings: A13a None identifiedA13b [dictate list, example: dysplasia; condyloma accuminatum; adenosis; other ____ Note: your

report should state what organs are involved by direct extension and / or by metastasis, including assessments of : Uterine cervix; Uterine corpus; Vagina; Vulva; Fallopian tubes; Ovaries; Bladder; Rectum

If an independent primary tumor present, use a second section with the appropriate staging information ]

24Vulva: biopsy or resection

X45 Vulvar Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 7th Ed.)

Tumor site: X51d UnknownX51e ________ [describe location, such as: Right vulva, labia major, etc.]

Tumor size: A2 ____ x ____ x ____ cm

Histologic type:

X4 Squamous cell carcinomaX4a SCC, keratinizing subtypeX4b SCC, non-keratinizing subtypeX4c SCC, verrucous subtypeX4d SCC, basaloid subtypeX4e SCC, warty type (condylomatous)

X6 AdenocarcinomaX6d Paget’s diseaseX6e Bartholin’s gland carcinoma, ___ [subtype]X6f Adenocarcinoma resembling breast carcinomaX6g Eccrine CarcinomaX9 (Other) _____


TNM (FIGO): F9x pTX (--): Cannot be assessed [Carcinomas only] F9 pT0 (--) [No evidence of primary tumor]

F9i pTis (--) [Carcinoma in situ] Note: if tumor also has a F11a pT1a (IA) [Tumor confined to vulva or perineum, < 2 cm in greatest dimension, metastasis, change the with stromal invasion < 1mm] FIGO stage to IVB, F11b pT1b (IB) [Tumor confined to vulva or perineum, either: whatever the TNM > 2 cm in greatest OR with stromal invasion > 1 mm] stage is. F12 pT2 (II) [Tumor of any size with extension to adjacent perineal structures: lower/distal

1/3 urethra, lower/distal 1/3 vagina, anus]F13x pT3 (IVA) [Tumor of any size with extension to any of the following: upper/proximal

2/3 of urethra, upper/proximal 2/3 of vagina, bladder mucosa, rectal mucosa, or

fixed to pelvic bone]Note: The depth of stromal invasion is defined as the measurement of the tumor from the epithelial-stromal

junction of the adjacent most superficial dermal papilla to the deepest point of invasion.

Regional lymph nodes:A6x pNX: Cannot be assessedA6 pN0: No tumor noted in ___ nodes pN1: Tumor present in 1 or 2 regional lymph nodes as follows: A7x pN1a: Tumor present in __ [1 or 2] of __ nodes (each metastasis < 5 mm)A7y pN1b: Tumor present in __ [1 or 2] of __ nodes, including only one metastasis measuring > 5 mm pN2: Tumor present in 1 or more lymph nodes with the following characteristics:A8x pN2a: Tumor present in __ [3 or more] of __ nodes (each metastasis < 5 mm)A8y pN2b: Tumor present in __ [2 or more] of __ nodes, including at least 2 metastases measuring > 5 mmA8z pN2c: Tumor present in __ of __ nodes, with focal extracapsular spreadA9x pN3: Tumor present in ___ of ___ nodes, with a fixed or ulcerated nodal metastasis




[Incomplete resection, margins involved by microscopic tumor]

A28b R2: ____ margin involved by tumor [Incomplete resection; gross tumor at margin]

25Vascular/Lymphatic vessel invasion: B30x Indeterminate

B30 Not identifiedB30a Present

Additional findings: A13a None identifiedA13b [dictate list, example: dysplasia; condyloma accuminatum; Vulvar intraepithelial neoplasia 3

(VIN3: severe dysplasia / carcinoma in situ); other ____]

Notes:Etiology/Pathogenesis: There are two pathways in the pathogenesis of invasive vulvar carcinoma.

1. The first pathway involves classic vulvar intraepithelial neoplasia (VIN), which is associated with high-grade human papillomavirus (HPV) subtypes (16 >18), and is histologically similar to dysplasia seen in the cervix. It tends to be multifocal and more common in younger women, with a relatively low risk of progression into an invasive squamous cell carcinoma. It is diffusely positive with p16 (reflecting HPV association) and is negative with p53. The associated invasive component is basaloid or warty in morphology.

2. The second pathway is referred to as differentiated VIN (VIN simplex). VIN simplex is not associated with HPV, but instead with vulvar dystrophy such as that seen in the context of lichen sclerosus or squamous hyperplasia. The morphologic features are more subtle, with atypia noted in the parabasal cells. The associated invasive component is keratinizing and can be associated with p53 mutations. This subtype usually occurs in older women. Most recently, cutaneous HPV subtypes (5,8) were found to be associated with this form. Of note, overlap does exist between the two pathways, with some tumors exhibiting morphologic and/or clinical features of each.

Gastrointestinal Lymphoma: resection

F56 Gastrointestinal Lymphoma Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 6th Ed.)

Tumor size(s): F69 Single tumor: ____ x ____ x ____ cmF70 Multiple tumors, ranging from ____ to ____ cm in diameter

Tumor immunophenotyping: F57 PerformedF58 Not performedF59 Previously performedF60 Submitted for outside phenotyping

Histologic type: [these are only examples of histologic types which you may use]F61 Hodgkin’s diseaseF62 Hodgkin’s disease, lymphocyte predominance, nodularF63 Hodgkin’s disease, nodular sclerosisF64 Hodgkin’s disease, mixed cellularityF65 Hodgkin’s disease, lymphocyte depletionF66 Hodgkin’s disease, unclassifiedF67 Non-Hodgkin’s lymphomaF68 B-cell Non-Hodgkin’s lymphoma F69 Extranodal marginal zone B-cell lymphoma (low grade B-cell lymphoma of MALT

type)F70 Mantle cell lymphoma (REAL Classification)F71 B-cell lymphoma, follicle center type (REAL Classification) F72 Burkitt’s lymphomaF73 T-cell Non-Hodgkin’s lymphomaF74 Intestinal T-cell lymphoma (gluten-sensitive enteropathy-associated)F75 Other: ____________

Histologic grade: [include if applicable]F76 Cannot be determinedF77 LowF78 High

Extent of invasion: F79 Cannot be assessedF80 Confined to mucosa/submucosaF81 Involvement of muscular wall/ subserosaF82 Penetration of serosa, with perforationF83 Penetration of serosa, without perforationF84 Direct extension to ______ [list other involved organs or structures]F85 Noncontiguous tumor involvement of ______ [list other involved organs or structures]




Note: Margins reviewed should include: proximal margin; distal margin; deep radial margin (if applicable).Regional lymph nodes: A6x pNX: Cannot be assessed

A6 pN0: No tumor noted in ___ nodesA7 pN1: Tumor present in ___ of ___ nodes

Nonregional lymph nodes: [if applicable] F89 No tumor involvement noted in ___ nonregional nodes


Additional findings: A13a None identifiedA13b [dictate list: ex., Helicobacter pylori gastritis; Celiac disease; other, ____ ]

Heart: resection 67H1 Heart Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 6th Ed.)

Tumor size: A2 ____ x ____ x ____ cm

Histologic type: H2 Sarcoma [specify subtype]H3 Lymphoma [specify subtype]H4 Carcinoma [specify subtype]

Histologic grade: [include if applicable]F76 Cannot be determinedF77 LowF78 High

Extent of invasion: [as appropriate]H5 Cannot be determinedH6 No involvement of adjacent tissue(s)H7 Involvement of adjacent tissue(s): ____ [list]H8 Other organ involvement: ______ [list]




Additional findings: A13a None identifiedA13b [dictate list: ex., benign tumor (specify: ____); Therapy-related changes (specify: _____);

inflammation; other, ____ ]

Hodgkin’s Disease: resection

H13 Hodgkin’s Disease Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 6th Ed.)Tumor immunophenotyping: F57 Performed

F58 Not performedF59 Previously performedF60 Submitted for outside phenotyping

Histologic type: F61 Hodgkin’s diseaseF62 Hodgkin’s disease, lymphocyte predominance, nodularF63 Hodgkin’s disease, nodular sclerosisF64 Hodgkin’s disease, mixed cellularityF65 Hodgkin’s disease, lymphocyte depletionH14 Hodgkin’s disease, lymphocyte-rich [provisional category]H15 Hodgkin’s disease, indeterminate for type

Histologic grade: [Nodular sclerosis only]H16 Grade I: < 25% of nodules show lymphocyte depletion

[or]H17 Grade I: < 25% of nodules show numerous anaplastic Hodgkin’s cells without

lymphocyte depletion--------------------

H18 Grade II: > 25% of nodules show lymphocyte depletion[or]

H19 Grade II: > 25% of nodules show numerous anaplastic Hodgkin’s cells withoutlymphocyte depletion

Stage: H20 Cannot be assessed--------------------

H21 Stage I: [def.: Involvement of a single lymph node region (I)][or]

H22 Stage I: [def.: Localized involvement of a single extralymphatic organ or site (IE)]--------------------

H23 Stage II: [def.: Involvement of two or more lymph node regions on the same side of diaphragm(II)][or]

HA22 Stage II: [def.: Localized involvement of a single associated extralymphatic organ or site and itsregional lymph nodes, with or without other lymph node regions on the same sideof the diaphragm (IIE)]

--------------------H25 Stage III: [def.: Involvement of lymph node regions on both sides of the diaphragm, with no

involvement of extralymphatic organ or spleen (III)][or]

H26 Stage III: [def.: Involvement of lymph node regions on both sides of the diaphragm, with involvement of extralymphatic organ or site, but not the spleen (IIIE)][or]

H27 Stage III: [def.: Involvement of lymph node regions on both sides of the diaphragm, with involvement of the spleen but not extralymphatic organs or sites (IIIS)][or]

H28 Stage III: [def.: Involvement of lymph node regions on both sides of the diaphragm, with involvement of extralymphatic organ/site and the spleen (IIIE,S)]

--------------------H29 Stage IV: [def.: Disseminated (multifocal) involvement of one or more extralymphatic organs with or

without associated lymph node involvement][or]

H30 Stage IV: [def.: Isolated extralymphatic organ involvement with distant (nonregional) nodal involvement]

Additional findings: A13a None identifiedA13b [dictate list: ex., progressively transformed germinal centers; hyaline vascular follicles;

hypervascular interfollicular regions; numerous interfollicular plasma cells; other, ____ ]

Tumor immunophenotyping: F57 PerformedF58 Not performedF59 Previously performedF60 Submitted for outside phenotyping

Histologic type (Revised European-American Lymphoma [REAL] Classification): L44 B cell lymphomaL45 B cell lymphoma, subtype cannot be determinedL46 Precursor B-lymphoblastic lymphomaL47 Precursor B-lymphoblastic lymphoma/ leukemiaL48 B-cell chronic lymphocytic leukemia / small lymphocytic lymphomaL49 B-cell promyelocytic leukemia / small lymphocytic lymphomaL50 Mantle cell lymphomaL51 Lymphoplasmacytic lymphoma

L52 Follicle center lymphoma, follicular, Grade IL53 Follicle center lymphoma, follicular, Grade IIL54 Follicle center lymphoma, follicular, Grade IIIL55 Follicle center lymphoma, diffuse predominantly small cell

L56 Extranodal marginal zone B-cell lymphoma (low grade B-cell lymphoma of MALT type)L57 Splenic marginal zone B-cell lymphomaL58 Hairy cell leukemiaL59 Plasmacytoma / plasma cell myeloma

L60 Diffuse large B-cell lymphomaL61 Primary mediastinal B-cell lymphomaL62 Burkitt’s lymphomaL63 High grade B-cell lymphoma, Burkitt-like

L64 T cell lymphomaL65 T cell lymphoma, subtype cannot be determinedL66 Precursor T-lymphoblastic lymphoma L67 Precursor T-lymphoblastic lymphoma / leukemiaL68 T-cell chronic lymphocytic leukemiaL69 T-cell prolymphocytic leukemiaL70 Large granular lymphocytic leukemia, T-cell typeL71 Large granular lymphocytic leukemia, NK-cell typeL72 Mycosis fungoides / Sezary’s syndromeL73 Peripheral T-cell lymphomaL74 Hepatosplenic gamma-delta T-cell lymphomaL75 Angioimmunoblastic T-cell lymphomaL76 Nasal / nasal type T/NK cell (angiocentric) lymphomaL77 Adult T-cell lymphoma / leukemiaL78 Anaplastic large cell lymphoma, T-cell typeL79 Anaplastic large cell lymphoma, Null cell type

Extent of Tumor: L80 Cannot be assessed

-------------------------

L81 Stage I [def.: involvement of a single lymph node region (location: ______ )] orL82 Stage I [def.: localized involvement of a single extralymphatic organ or site (location: ____ )]

-------------------------

L83 Stage II [def.: involvement of two or more lymph node regions on the same side of the diaphragm]

orL84 Stage II [def.: localized involvement of a single associated extralymphatic organ or site and its

regional lymph nodes with or without other lymph node regions on the same side of the diaphragm]

-------------------------

L85 Stage III [def.: involvement of lymph node regions on both sides of the diaphragm, and: [include those that apply]

L86 Localized involvement of an extralymphatic organ or site (location: ____ )]L87 Involvement of any extralymphatic organ or site is unknown]L88 Involvement of spleen]L89 Involvement of spleen is unknown]

-------------------------

L90 Stage IV [def.: disseminated (multifocal) involvement of one or more extralymphatic organ,and:

[include those that apply]L91 Associated lymph node involvement present]L92 Associated lymph node involvement is unknown]L93 Distant (nonregional) nodal involvement present]L94 Distant (nonregional) nodal involvement is unknown]

Additional findings: A13a None identifiedA13b [dictate list, ____]

Ovary: Second-look staging

O1 Ovarian Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 6th Ed.)

[ for each site do the following]

Tumor invasion: O42 Cannot be assessedO43 Noninvasive tumor notedO44 Invasive tumor noted

Histologic type: O45 Same as primary tumorO46 Other, specify: _______

Histologic grade: O47 Same as primary tumorO48 Other, specify: _______

Additional findings: A13a None identifiedA13b [dictate list, example: endometriosis (ovarian, extraovarian); endosalpingiosis; other ____]

Trophoblast: resection

T21 Gestational Trophoblast Tumor (GTT) Staging Information (data derived from current specimen; in accord with theAJCC Cancer Staging Manual, 6th Ed.)

Tumor size: A2 ____ x ____ x ____ cm

Histologic type: T22a Hydatidiform mole, completeT22b Hydatidiform mole, partialT22c Invasive hydatidiform moleT22d ChoriocarcinomaT22e Placental site trophoblastic tumorT22f Trophoblastic lesion, consistent with exaggerated placental siteT22g Trophoblastic lesion, consistent with placental site nodule and plaqueT22h Unclassified trophoblastic lesion

TNM (FIGO): F11 pT1 (I): [Disease confined to uterus]F12 pT2 (II): [GTT extends outside of uterus but limited to genital structures

(adnexa, vagina, or broad ligament)]

Distant metastasis: A10x pMX: Cannot be assessedA10 pM0: No distant metastasisA11 pM1: Present, involving ___A11a pM1a: Present, involving: ___ [Lung metastasis]A11b pM1b: Present, involving: ___ [All other distant metastasis]

Regional lymph nodes: There is no regional nodal staging for this tumor




Note: Margin review includes: cervical/vaginal margin, right or parametrial margin.


Additional findings: A13a None identifiedA13b [dictate list, example: implantation site; fetal tissue (including cord, amnion, chorion, yolk

sac); fetal anomalies (specify: ________); other ____ Note: your reportshould state what organs are involved by direct extension and / or by metastasis, including assessments of : Uterine cervix

Uterine corpusVaginaVulvaFallopian tubesOvariesBladderRectum

If an independent primary tumor present, use a second section with the appropriate staging information

A1 Skin Tumor Staging Information (data derived from current specimen; in accord with the AJCC Cancer xx Staging Manual, 6th Ed.)

Note 1: This is some skin tumors, particularly adnexal carcinomas, Merkel cell carcinoma, and Paget’s disease. Note 2: This protocol is not for melanoma, sarcoma or hematopoietic malignancy.Note 2: You could use it for basal cell carcinoma or squamous cell carcinoma, but these tumors are not routinely staged or

reported to cancer registries.Note 3: This protocol does not include eyelid, vulva, or penis sites.

Specimen type: xx Not specifiedxx EllipseXx ShavingsXx CurettingsXx Other [specify]: ________

Tumor site: xx Not specifiedXx [specify]: _______

Tumor size: xx Cannot be determinedA2 ____ x ____ x ____ cm

Histologic type: xx Adnexal carcinoma, NOSXx Eccrine carcinomaXx Sclerosing sweat duct carcinoma (syringomatous carcinoma, microcystic adnexal carcinoma)Xx Malignant mixed tumor of the skin (malignant chondroid syringoma)Xx PorocarcinomaXx Malignant nodular hidradenomaXx Malignant eccrine spiradenomaXx Mucinous eccrine carcinomaXx Adenoid cystic eccrine carcinomaXx Aggressive digital papillary adenoma/ adenocarcinomaXx Apocrine carcinomaXx Sebaceous carcinomaXx TricholemmocarcinomaXx Malignant pilomatricoma (matrical carcinoma)Xx Other [specify]:Xx Merkel cell carcinomaXx Merkel cell carcinoma, with fewer than 10 mitoses per 10 high power fieldsXx Merkel cell carcinoma, with 10 or more mitoses per 10 high power fieldsXx Paget diseaseXx Mammary Paget diseaseXx Extramammary Paget diseaseXx Other [specify]: ________

Histologic grade: A18n Not applicable (if applicable to A18x GX: Cannot be assessed tumor type) A18a G1: Well differentiated


Staging: xx pTX: Primary tumor cannot be assessedXx pT0: No evidence of primary tumor

Note: Xx pTis: Carcinoma in situgreatest dimension Xx pT1: Tumor < 2 cm in greatest dimensionvs. Xx pT1a: Limited to dermis, or < 0.2 cm in thicknessthickness Xx pT1b: Limited to dermis and > 0.2 cm in thickness, but not > 0.6 cm in thickness

Xx pT1c: Invading the subcutis and/or > 0.6 cm in thicknessXx pT2: Tumor > 2 cm but not > 5 cm in greatest dimensionXx pT2a: Limited to dermis, or < 0.2 cm in thicknessXx pT2b: Limited to dermis and > 0.2 cm in thickness, but not > 0.6 cm in thicknessXx pT2c: Invading the subcutis and/or > 0.6 cm in thicknessXx pT3: Tumor > 5 cm in greatest dimension

Xx pT3a: Limited to dermis, or < 0.2 cm in thicknessXx pT3b: Limited to dermis and > 0.2 cm in thickness, but not > 0.6 cm in thicknessXx pT3c: Invading the subcutis and/or > 0.6 cm in thicknessXx pT4: Tumor invades the deep extradermal tissue [eg.: cartilage, bone, skeletal muscle]Xx pT4a: Tumor < 0.6 cm in thicknessXx pT4b: Tumor > 0.6 cm in thickness

Regional lymph nodes: Note: If “isolated tumor cells” present (ie., single cells or small clusters not more than 0.2 mm in greatest dimension), use the ITC categories (i- and i+).

B18x pNX: Cannot be assessed [def.: cannot be assessed -- previously removed or not removed]B18 pN0: No tumor noted in __ lymph nodes [def.: No regional lymph node metastasis; no immunos done]B19 pN0(i-): No tumor, including isolated tumor cells, noted in __ lymph nodes by H&E stain or

immunohistochemistryB19s pN0(i-) (sn): No tumor, including isolated tumor cells, noted in __ sentinel lymph nodes H&E stain or

immunohistochemistryB20 pN0(i+): Only isolated tumor cells (ITCs) noted in __ of __ lymph nodes by H&E stain or

immunohistochemistry; no ITC cluster > 0.2 mmB20s pN0(i+) (sn): Only isolated tumor cells (ITCs) tumor noted in __ of __ sentinel lymph nodes by H&E stain

or immunohistochemistry, no ITC cluster > 0.2 mm.B19m pN0(mol-): No tumor noted in __ lymph nodes by H&E stain, negative molecular findings (RT-PCR)B19ms pN0(mol-) (sn): No tumor noted in __ sentinel lymph nodes by H&E stain, negative molecular

findings (RT-PCR)B20m pN0(mol+): No tumor noted in __ lymph nodes by H&E stain, positive molecular findings (RT-PCR)B20ms pN0(mol+) (sn): No tumor noted in __ sentinel lymph nodes by H&E stain, positive molecular

findings (RT-PCR)B21 pN1: Tumor present in __ of __ lymph nodes





Lateral Margins: xx Cannot be assessedXx Uninvolved by invasive carcinoma; distance from closest margin: ___ cm ( ___ margin)Xx Involved by invasive carcinoma: ___ margin

If involvement of lateral margin by carcinoma in situ is relevant, then add something appropriate such as “(Un)involved by carcinoma in situ; distance from closest margin: ___ cm ( ___ margin)

Deep Margin: xx Cannot be assessedXx Uninvolved by invasive carcinoma; distance from deep margin: ___ cmXx Involved by invasive carcinoma [specify location, if possible]


Perineural invasion: A29a Not identifiedA13ab Present

Additional pathologic findings: A13a None identifiedA13b specify ____

71Z1 Melanoma of the Skin Staging Information (data derived from current specimen; in accord with the AJCC Cancer Staging Manual, 6th Ed.)Specimen type: Z2a Not specified

Z2b Excision, [specify type – ellipse, wide, other]Z2c Re-excision, [specify type – ellipse, wide, other]

Z2d Other [specify]: ________ Macroscopic tumor: Z3a Absent

Z3b Present Z3c Indeterminate

Tumor site: Z4a Not specified Z4b [specify]: _______

Tumor size: Z5a Cannot be determined A2 ____ x ____ x ____ cm

A2a Greatest dimension: ___ cm Satellite nodule(s): Z3a Absent

Z3b Present Z3c Indeterminate

Histologic type: Z7a Superficial spreading melanomaZ7b Lentigo maligna melanomaZ7c Nodular melanomaZ7d Acral lentiginous melanomaZ7e Mucosal-lentiginous melanomaZ7f Desmoplastic (spindle desmosplastic; neuroid) melanomaZ7g Neurotropic melanomaZ7h Malignant blue nevusZ7i Melanoma in congenital melanocytic nevusZ7j Minimal deviation (nevoid) melanomaZ7k Melanoma, type cannot be determined

Z7m Other [specify]: Ulceration: Z8a Absent

Z8b Present Depth of invasion: Z9a __ mm

Z9b Cannot be determined Staging: Z10 pTX: Primary tumor cannot be assessed

Z11 pT0: No evidence of primary tumor Z12 pTis: Melanoma in situ [ie., non-invasive; level 1]

Z13 pT1 [melanoma < 1.0 mm in thickness, with or without ulceration]Z13a pT1a [melanoma < 1.0 mm in thickness, level II or III, without ulceration]

Z13b pT1b [melanoma < 1.0 mm in thickness, level IV or V, or with ulceration]Z14 pT2 [melanoma 1.01 to 2.0 mm in thickness, with or without ulceration]

Z14a pT2a [melanoma 1.01 to 2.0 mm in thickness, without ulceration] Z14b pT2b [melanoma 1.01 to 2.0 mm in thickness, with ulceration]

Z15 pT3 [melanoma 2.01 to 4.0 mm in thickness, with or without ulceration]Z15a pT3a [melanoma 2.01 to 4.0 mm in thickness, without ulceration]

Z15b pT3b [melanoma 2.01 to 4.0 mm in thickness, with ulceration]Z16 pT4 [melanoma greater than 4.0mm in thickness, with or without ulceration]Z16a pT4a [melanoma greater than 4.0mm in thickness, without ulceration]

Z16b pT4b [melanoma greater than 4.0mm in thickness, with ulceration] Clark level: Z6a I [intraepidermal tumor only]

Z6b II [tumor invades papillary dermis]Z6c III [tumor invades papillary dermis and expands it]Z6d IV [tumor invades reticular dermis]

Z6e V [tumor invades subcutis] Regional lymph nodes:

Note 1: If “isolated tumor cells” present (ie., single cells or small clusters not more than 0.2 mm in greatest dimension), use the ITC category (i+).

Note 2: If you have SATELLITE METASTASIS (clinical or microscopic) or IN-TRANSIT METASTASIS, use pN2c or pN3 even if there are 0 or <4 nodal mets, respectively.

B18x pNX : Cannot be assessed [def.: cannot be assessed -- previously removed or not removed]

B18 pN0: No tumor noted in __ lymph nodes [def.: No regional lymph node metastasis; no immunos done]B19 pN0(i-): No tumor, including isolated tumor cells, noted in __ lymph nodes by H&E stain or

immunohistochemistryB19s pN0(i-) (sn): No tumor, including isolated tumor cells, noted in __ sentinel lymph nodes H&E stain or

immunohistochemistryB20 pN0(i+): Only isolated tumor cells (ITCs) noted in __ of __ lymph nodes by H&E stain or

immunohistochemistry; no ITC cluster > 0.2 mmB20s pN0(i+) (sn): Only isolated tumor cells (ITCs) tumor noted in __ of __ sentinel lymph nodes by H&E stain or immunohistochemistry, no ITC cluster > 0.2 mm. Z21 pN1: Tumor present in 1 of ___ lymph node(s)Z21a pN1a: Clinically occult (microscopic) tumor present in 1 of ___ lymph node(s)Z21b pN1b : Clinically apparent (macroscopic) tumor present in 1 of ___ lymph node(s) Z22 pN2: Tumor present in __ of __ lymph nodes [tumor in 2-3 nodes]Z22a pN2a: Clinically occult (microscopic) tumor present in ___ of ___ lymph node(s) [tumor in 2-3 nodes]Z21b pN2b: Clinically apparent (macroscopic) tumor present in ___ of ___ lymph node(s) [tumor in 2-3 nodes]Z21c pN2c : Satellite or in-transit metastasis without nodal metastasis Z23 pN3: Tumor present in __ of __ lymph nodes [tumor in 4 or more nodes, or in matted lymph nodes] ORZ24 pN3: Tumor present in __ of __ lymph nodes, with satellite or in-transit metastasis also present [tumor in 1 or or more lymph nodes ]

Distant metastasis: A10x pMX: Cannot be assessedA10 pM0: No distant metastasisA11 pM1: PresentA11a pM1a: Present, involving ___ [Met to skin, subcutaneous tissues, or distant lymph nodes]A11b pM1b: Present, involving ___ [Met to lung]A11c pM1c: Present, involving ___ [Met to all other visceral sites or distant metastasis at any

site associate with an elevated serum lactic dehydrogenase (LDH)] Margin evaluation: A28x RX [presence of residual tumor cannot be assessed]

A28 R0: Margins free of tumor. Distance of tumor from closest margin: ____ cm ( ____margin)[Complete resection, no residual tumor left after resection]

A28a R1: ____ margin involved by microscopic tumor[Incomplete resection, margins involved by microscopic tumor]

A28b R2: ____ margin involved by tumor [ Incomplete resection; gross tumor at margin] Lateral Margins: xx Cannot be assessed

Xx Uninvolved by invasive melanoma; distance from closest lateral margin: ___ cm ( ___ margin)Xx Involved by invasive melanoma: ___ margin

If involvement of lateral margin by melanoma in situ is relevant, then add one of these: Xx Uninvolved by melanoma in situ; distance from closest margin: ___ cm ( ___ margin)

Xx Involved by melanoma in situ: ___ margin Deep Margin: xx Cannot be assessed

Xx Uninvolved by invasive melanoma; distance from deep margin: ___ cm Xx Involved by invasive melanoma [specify location, if possible]


Perineural invasion: A29a Not identified A13ab Present

Tumor-Infiltrating lymphocytes: Xx AbsentXx Nonbrisk

Xx Brisk Tumor regression: Xx Absent

Xx Present involving less than 75% of the lesion Xx Present involving more than 75% of the lesion

Mitotic index: Xx Less than 1 mitotic figure per mm2

Xx 1 or more mitotic figure per mm 2 Additional pathologic findings: A13a None identified

A13b specify ____ [nevus remnant; actinic keratosis; other]

44J1 Peripheral Blood:J1a

J2 RBC morphology: J2a Normochromic, normocytic erythrocytes.J2b Nucleated RBCs present.J2c Teardrop (dacrocytes) present.J2d Howell-Jolly bodies identified.J2e Target cell present.J2f Schistocytes present.J2g Rouleax formation identified. J3 WBC morphology: J3a Neutrophils normally segmented, lymphocytes unremarkable, no blasts identified. [Neutrophils normally segmented with adequate cytoplasmic granulation, no blasts identified, lymphocytes unremarkable.]J3b Blast forms present with immature chromatin, prominent nucleoli, and scant cytoplasm.J3c Auer rods within blasts present.J3d Auer rods not identified.J3e Immature monocyte forms with abundant cytoplasm, consistent with promonocytes/monoblasts.J3f Scattered myelocytes and metamyelocytes present.J3g Hyposegmented neutrophils (pseudo Pelger-Hüet cells) present.J3h Hypogranular neutrophils present.J3i Hypersegmented neutrophils with 5 lobes identified. J3j Hypersegmented neutrophils with 5 and 6 lobes identified. J4 Platelet morphology:J4a Adequate numbers of platelets with unremarkable morphology.J4b Giant platelets present.J4c Platelets decreased in number.J4d Platelet clumping present. J5 Bone marrow aspirate:J5a Quality: J5b Cellular with adequate numbers of spiculesJ5c Hypocellular with rare spicules.J5d Hemodilute and without spicules.J5e [other] J5f Myeloid to erythroid ratio: ______ J6 Myeloid precursors:J6a Adequate and progressive maturationJ6b Increased blast forms present ( __%).J6c Giant bands and atypical neutrophils are present.J6d Auer rods within blasts present.J6e Auer rods not identified. J7 Erythroid precursors:J7a Adequate and progressive maturationJ7b Minimal dyserythropoiesis.J7c Mild to moderate dyserythropoiesis.J7d Marked dyserythropoiesis.J7e Nuclear budding and multi-nucleation noted.J7f Megaloblastoid changes with nuclear-cytoplasmic dyssynchrony.J7g Marked erythroid hyperplasia.J5e [other]

Hgb WBC % eos Hct % neut % baso MCV % lymph % blasts RDW % mono

J8 Megakaryocytes: 45J8a Present in adequate numbers with unremarkable morphology.J8b Increased in number.J8c Decreased in number.J8d Hypolobated megakaryocytes present.J8e Megakaryocytes with denuded cytoplasm present.J5e [other]J9 Lymphocytes/Plasma cells:J9a No increase in lymphocytes (less than 15%) or plasma cells (1% or less)J9b Increased lymphocytes present ( ___%).J9c Increased plasma cells present ( ___%).J9d Plasma cells with Dutcher bodies (nuclear inclusions) present.J9e Plasma cells with Russell bodies (cytoplasmic inclusions) present .J5e [other]J10 Other:J10a No metastatic tumor clusters identified. J11 Bone marrow core biopsy / clot specimenJ11a Quality: Core biopsy and clot adequate.J11b Quality: Core biopsy adequate.J11b Quality: Core biopsy contains inadequate numbers of hematopoietic precursors.J11c Quality: Clot specimen adequate with numerous spicules.J11d Quality: Clot specimen inadequate, with rare spicules.J11e Quality: Clot specimen inadequate, with no spicules.J11f Quality: [other]J11g Cellularity: __% J12 Megakaryocytes:J12a Adequate numbers present. Unremarkable morphology. No clustering.J12b Scattered micromegakaryoctes present.J12c Megakaryocytes with denuded cytoplasm present.J12d Megakaryocyte clustering present.J12e Hypolobated megakaryocytes present.J12f Hyperlobated megakaryocytes present. J13 Lymphoid aggregates / infiltrates:J13a No atypical aggregates or lymphoid infiltrates identified.J13b Small well-circumscribed interstitial lymphoid aggregates associated with blood vessels.J13c Large atypical interstitial lymphoid aggregates present involving __% of marrow space.J13d Atypical paratrabecular lymphoid aggregates present involving __% of marrow space. J14 Granulomas:J14a No granulomas identified.J14b Epitheloid granulomas present.J14c Lipogranulomas present.J14d Ring granulomas present. J15 Other:J15a No evidence of metastatic carcinoma.J15b Clusters of metastatic tumor present involving __% of marrow space.J15c Collagenous fibrosis present.J15d Increased osteoclastic activity present.J15e Increased osteoblastic activity present.J15f Eosinophilc material suspicious for amyloid identified (see below). J16 StainsJ16a __+ Iron (scale 0 to 4+) in aspirate smear, core biopsy, and/or clot specimen staining. J16b No increase in ringed sideroblasts.J16c Increased (>15%) ringed sideroblasts present: ___% on the aspirate smearJ16d __+ reticulin fibrosis (scale of 0 to 3+).J16e __ [+/-] for amyloid by Congo Red stain.J16f Immunostains performed on the __ [core/clot specimen] show the following:

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