COLON AND RECTUM: RESECTION, INCLUDING TRANSANAL DISK EXCISION
OF RECTAL NEOPLASMS CASE SUMMARY
MNEUMONIC – COLRENET12
COLON AND RECTUM: RESECTION, INCLUDING TRANSANAL DISK EXCISION
OF RECTAL NEOPLASMS CASE SUMMARY
SPECIMEN
Large intestine
Cecum
Ascending colon
Transverse colon
Descending colon
Sigmoid colon
Rectum
Anus
Terminal ileum
Appendix
Other (specify):
Not specified
PROCEDURE
Right hemicolectomy
Transverse colectomy
Left hemicolectomy
Sigmoidectomy
Rectal/rectosigmoid colon (low anterior resection)
Total abdominal colectomy
Abdominoperineal resection
Transanal disk excision (local excision)
Other (specify):
Not specified
SPECIMEN SIZE (applicable to transanal disk excision)
Specify: (length) x x cm
TUMOR SITE
Large bowel
Cecum
Right (ascending) colon
Hepatic flexure
Transverse colon
Splenic flexure
Left (descending) colon
Sigmoid colon
Rectum
Other (specify):
Not specified
TUMOR LOCATION
Tumor is located above peritoneal reflection
Tumor is located below the peritoneal reflection
Not specified
TUMOR SIZE
Greatest dimension: cm (specify size of largest tumor if multiple tumors are present)
Additional dimensions: x cm
Cannot be determined (see “Comment”)
TUMOR FOCALITY
Unifocal
Multifocal (specify number of tumors:
Cannot be determined
)
HISTOLOGIC TYPE AND GRADE
Not applicable
Well-differentiated neuroendocrine tumor; GX: Grade cannot be assessed
Well-differentiated neuroendocrine tumor; G1: Low grade
Well-differentiated neuroendocrine tumor; G2: Intermediate grade
Other (specify):
#
For poorly differentiated neuroendocrine carcinomas, the College of American Pathologists (CAP) checklist for
carcinoma of the colon and rectum should be used.
MITOTIC RATE
Specify: /10 high-power fields (HPF)
Cannot be determined
MICROSCOPIC TUMOR EXTENSION
Cannot be assessed
No evidence of primary tumor
Tumor invades lamina propria
Tumor invades into but not through muscularis mucosae
Tumor invades submucosa
Tumor invades muscularis propria
Tumor invades through the muscularis propria into the subserosal adipose tissue or the
nonperitonealized pericolic or perirectal soft tissues but does not extend to the serosal
surface (visceral peritoneum)
Tumor penetrates serosa (visceral peritoneum)
Tumor directly invades adjacent structures (specify:
)
Tumor penetrates to the surface of the visceral peritoneum (serosa) and directly invades adjacent
structures (specify:
)
MARGINS
If all margins uninvolved by neuroendocrine tumor:
Distance of tumor from closest margin:
Specify margin:
Proximal Margin
Cannot be assessed
Uninvolved by neuroendocrine tumor
Involved by neuroendocrine tumor
Distal Margin
Cannot be assessed
Uninvolved by neuroendocrine tumor
Involved by neuroendocrine tumor
Circumferential (Radial) Margin
Cannot be assessed
Uninvolved by neuroendocrine tumor
Involved by neuroendocrine tumor
Not applicable
Other Margin(s) (specify):
Cannot be assessed
Uninvolved by neuroendocrine tumor
Involved by neuroendocrine tumor
LYMPH-VASCULAR INVASION
Not identified
Present
Indeterminate
mm or
cm
PERINEURAL INVASION
Not identified
Present
Indeterminate
PATHOLOGIC STAGING (pTNM)
TNM Descriptors (required only if applicable)
m (multiple primary tumors)
r (recurrent)
y (posttreatment)
PRIMARY TUMOR (pT)
pTX:
Primary tumor cannot be assessed
pT0:
No evidence of primary tumor
pT1:
Tumor invades lamina propria or submucosa and size 2 cm or less
pT1a:
Tumor size less than 1 cm in greatest dimension
pT1b:
Tumor size 1 to 2 cm in greatest dimension
pT2:
Tumor invades muscularis propria or size more than 2 cm with invasion of lamina
propria or submucosa
pT3:
Tumor invades through the muscularis propria into the subserosa, or into
nonperitonealized pericolic or perirectal tissues
pT4:
Tumor invades peritoneum or other organs
REGIONAL LYMPH NODES (pN)
No nodes submitted or found
Cannot be assessed
pN0: No regional lymph node metastasis
pN1: Metastasis in regional lymph nodes
Specify: Number of lymph nodes examined:
Number cannot be determined (explain):
Number of lymph nodes involved:
Number cannot be determined (explain):
DISTANT METASTASIS (pM)
Not applicable
pM1: Distant metastasis
Specify site(s), if known:
ANCILLARY STUDIES
Ki-67 index (specify: )
≤2%
3% to 20%
>20%
Other (specify):
Not performed
ADDITIONAL PATHOLOGIC FINDINGS
Tumor necrosis
Other (specify):
Pathologic TNM (AJCC 7th edition): pT N M