REPORTING SHEET FOR COLORECTAL CARCINOMA (includes neuroendocrine carcinoma and MiNEN but excludes well-differentiated neuroendocrine tumours)
CLINICAL:
Clinical history:
Neoadjuvant therapy: Administered / Not administered / Not specified Operative procedure: Abdominoperineal resection / Anterior resection, high / Anterior resection, low / Anterior resection, not further specified / Hemicolectomy, left / Hemicolectomy, right / Hemicolectomy, right extended / Hartmann's procedure / Proctocolectomy / Sigmoid colectomy / Transverse colectomy / Total colectomy / Not specified / Other
If other: specify
MACROSCOPIC:
Tumour site: C18.0 Caecum / C18.2 Colon, ascending / C18.3 Colon, hepatic flexure / C18.4 Colon, transverse / C18.5 Colon, splenic flexure / C18.6 Colon, descending / C18.7 Sigmoid colon / C18.9 Colon, not otherwise specified / C19.9 Colon, rectosigmoid / C20. 9 Rectum / Not identified / Other
If other: specify
Maximum tumour dimension: mm
Additional tumour dimensions (optional): x mm
Perforation: Not identified / Present, not involving tumour / Present, through tumour (tumour perforation) Note: This element refers to perforation that is evident on macroscopy
Other macroscopic:
Key to blocks:
For rectal cancers only: Relation to anterior peritoneal reflection: Astride / Entirely above / Entirely below / Not applicable Plane of mesorectal excision: Intramesorectal (near complete) / Muscularis propria (incomplete) / Mesorectal fascia (complete) / Not applicable
MICROSCOPIC:
Histological tumour type: Adenocarcinoma not otherwise specified (NOS) 8140/3 / Serrated adenocarcinoma 8213/3 / Adenoma-like adenocarcinoma 8262/3 / Micropapillary adenocarcinoma (>=5% micropapillary morphology) 8265/3 / Mucinous adenocarcinoma (>50% mucinous differentiation) 8480/3 / Signet-ring cell adenocarcinoma (>50% signet-ring cells) 8490/3 / Medullary carcinoma 8510/3 / Mixed neuroendocrine-non-neuroendocrine neoplasm (MiNEN) 8154/3 / Neuroendocrine carcinoma, large cell type 8013/) / Neuroendocrine carcinoma, small cell type 8041/3 / No evidence of residual tumour / Other
If into other structures: specify
Lymphovascular and perineural invasion:
Small vessel: Not identified / Present Large vessel (venous), intramural: Not identified / Present Large vessel (venous), extramural: Not identified / Present Perineural invasion: Not identified / Present
Lymph node status:
Number of lymph nodes examined: Number of involved lymph nodes: Tumour deposits: Not identified / Present, specify number below Tumour deposits, number
Tumour budding: Bd1 – low budding (0–4 buds) / Bd2 – intermediate budding (5–9 buds) / Bd3 – high budding (>=10 buds) / Cannot be assessed / Not applicable
Response to neoadjuvant therapy: Complete response – no viable cancer cells (score 0) / Near complete response – single cells or rare groups of cancer cells (score 1) / Partial response – residual cancer with evident tumour regression (score 2) / Poor or no response – extensive residual cancer with no evident tumour regression (score 3) / Cannot be assessed / Not applicable – no known neoadjuvant therapy
If cannot be assessed: reason:
Margin status:
Longitudinal margin status: Cannot be assessed / Proximal margin involved / Distal margin involved / Proximal and distal margins involved / Longitudinal margin involved, unspecified / Not involved
If not involved: distance to margin:        mm
Circumferential margin status: Cannot be assessed / Involved: specify 0 mm or to nearest 0.1 mm below / Not involved: estimate distance to nearest 1 mm or >=10 mm below Note: The circumferential margin is considered to be involved if tumour is 1 mm or less from the margin
If not involved (>1 mm): distance to margin:        mm (specify distance to nearest 1 mm or ≥10 mm) If involved (≤1mm): distance to margin:        mm (specify 0 mm or distance to nearest 0,1 mm) If involved (≤1mm), involved by: Direct extension of primary tumour to margin / Focus of lymphovascular invasion present at margin / Positive lymph node at circumferential margin / Tumour deposit present at margin / Other: specify below
If other: specify:
Coexistent pathology:
Polyp(s): Not identified / Present, specify type and number below If present: type and number:
Co-existent pathology: Not identified / Present, describe below If present, specify:
Ancillary studies:
Mismatch repair (MMR) IHC (mandatory for patients < 60 years): Not done / Performed on previous specimen / Performed on this specimen / Result to follow MLH1: Cannot be determined / Normal retained nuclear expression / Abnormal loss of nuclear expression / Not done / Result to follow
If cannot be determined: reason:
PMS2: Cannot be determined / Normal retained nuclear expression / Abnormal loss of nuclear expression / Not done / Result to follow
If cannot be determined: reason:
MSH2: Cannot be determined / Normal retained nuclear expression / Abnormal loss of nuclear expression / Not done / Result to follow
If cannot be determined: reason:
MSH6: Cannot be determined / Normal retained nuclear expression / Abnormal loss of nuclear expression / Not done / Result to follow
If cannot be determined: reason:
BRAF V600E testing: Cannot be determined: provide reason below / Not done / Negative for cytoplasmic staining by immunohistochemistry / Positive cytoplasmic staining by immunohistochemistry / Negative for BRAF V600E mutation by PCR testing / Positive for BRAF V600E mutation by PCR testing Note: BRAFV600E testing is generally indicated with MLH1 and PMS2 loss to distinguish between cases with sporadic MMR deficiency and possible Lynch syndrome
If cannot be determined: reason:
Comment for MMR IHC:
Loss of nuclear expression of MSH6 only: High probability of Lynch syndrome. Referral to a genetic counsellor ± further genetic testing to confirm or exclude Lynch syndrome is advised. Loss of nuclear expression of MSH2 and MSH6: High probability of Lynch syndrome. Referral to a genetic counsellor ± further genetic testing to confirm or exclude Lynch syndrome is advised. Loss of nuclear expression of PMS2 only: High probability of Lynch syndrome. Referral to a genetic counsellor ± further genetic testing to confirm or exclude Lynch syndrome is advised. Loss of nuclear expression of MLH1 & PMS2, BRAFV600E negative: absence of BRAFV600E mutation suggests the possibility of Lynch syndrome. Referral to a genetic counsellor ± further genetic testing is advised to exclude or confirm Lynch syndrome. Loss of nuclear expression of MLH1 and PMS2, BRAFV600E positive: the presence of a BRAF V600E mutation and/or MLH1 methylation suggests that the tumour is sporadic and germline evaluation is probably not indicated. Normal retained nuclear staining for PMS2 and MSH6 makes Lynch syndrome unlikely. Normal retained nuclear staining for MLH1, PMS2, MSH2 and MSH6 makes Lynch syndrome unlikely. MSI status by PCR: Microsatellite instability high (MSI-H) / Microsatellite instability low (MSI-L) / Microsatellite stable (MSS) / Not tested / Test failed
Other ancillary tests:
Histologically confirmed distant metastasis:
Distant metastasis: Not identified / Present, specify site below
If present: specify site:
COMMENT:
PATHOLOGICAL STAGING (AJCC/UICC TNM 8th edition):
TNM descriptor 1: m – multiple primary tumours / r – recurrent / y – post therapy / Not applicable TNM descriptor 2: m – multiple primary tumours / r – recurrent / y – post therapy Primary tumour: (Will be automatically completed from information already provided above) Regional lymph nodes: N0: No regional lymph node metastasis / N1a: Metastasis in 1 regional lymph node / N1b: Metastasis in 2 to 3 regional lymph nodes / N1c: Tumour deposit(s), i.e. satellites, in the subserosa or in non-peritonealized pericolic or perirectal soft tissue without regional lymph node metastases / N2a: Metastasis in 4 to 6 regional lymph nodes / N2b: Metastasis in 7 or more regional lymph nodes / NX: Regional lymph nodes cannot be assessed Distant metastasis: M1a: Metastasis confined to one organ (liver, lung, ovary, non-regional lymph node(s)) without peritoneal metastasis / M1b: Metastasis in more than one organ / M1c: Metastasis to the peritoneum with or without organ involvement / Not applicable
DIAGNOSIS:
Tumour site: (Will be automatically completed from information already provided above) Procedure: (Will be automatically completed from information already provided above) Histological type: (Will be automatically completed from information already provided above) Histological grade: (Will be automatically completed from information already provided above) Surgical margins: R0: No residual tumour (margins clear) / R1: Microscopic residual tumour / R2: Macroscopic residual tumour at the primary cancer site or regional node sites / RX: Presence of residual tumour cannot be assessed MMR status by IHC: MMR deficient / MMR proficient / Not tested MSI status by PCR: (Will be automatically completed from information already provided above)
REPORTED BY:
REGISTRAR:
PATHOLOGIST: