RCPA Colorectal Structured Report
Based on ICCR Structured Report v4.2 Nov 2020 & produced with PathNotes RCPA Colorectal v1.0 [
user manual
]
* - Standard items
DEMOGRAPHICS
Date of request:
*
Accession number:
Patient identifier(s):
Family name:
Given name(s):
Date of birth:
Sex:
Male
Female
Intersex/indeterminate
Ethnicity:
Unknown
Aboriginal/Torres Strait Islander (AU)
Maori
Other ethnicity
Requesting doctor:
CLINICAL INFORMATION
Information not provided
Known polyposis syndrome
Familial adenomatous polyposis (FAP)
MUTYH-associated polyposis (MAP)
Serrated polyposis
Other (specify)
Lynch syndrome
Chronic inflammatory bowel disease
Ulcerative colitis
Crohn disease
Previous polyp(s)
Previous colorectal cancer
Other (specify)
*
NEOADJUVANT THERAPY
Information not provided
Not administered
Administered (describe)
*
OPERATIVE PROCEDURE:
Total colectomy
Proctocolectomy
Right hemicolectomy
Extended right hemicolectomy
Transverse colectomy
Left hemicolectomy
Sigmoid colectomy
Anterior resection
High anterior resection
Low anterior resection
Hartmann's procedure
Abdominoperineal resection
Other
MACROSCOPIC
*
SPECIMEN LABELLED:
*
SPECIMEN LENGTH:
*
TUMOUR SITE:
Not specified
Caecum
Ascending colon
Hepatic flexure
Transverse colon
Splenic flexure
Descending colon
Sigmoid colon
Rectosigmoid
b
Rectum
*
RELATION OF TUMOUR TO ANTERIOR PERITONEAL REFLECTION:
Entirely above
Astride
Entirely below
Other
b
Reserved for cases where determination between rectum and sigmoid cannot be made
*
PLANE OF MESORECTAL EXCISION:
Mesorectal fascia (complete)
Intramesorectal (near complete)
Muscularis propria (incomplete)
PLANE OF SPHINCTER EXCISION:
Extralevator plane
Sphincter plane
Intrasphincteric plane
PLANE OF MESOCOLIC EXCISION:
Mesocolic plane
Intramesocolic plane
Muscularis propria plane
*
TUMOUR DIMENSIONS:
Cannot be assessed
Maximum tumour dimension:
mm
Additional dimensions (optional):
mm
DISTANCE OF TUMOUR TO NEARER PROXIMAL OR DISTAL 'CUT END':
DISTANCE OF TUMOUR TO THE NONPERITONEALISED CIRCUMFERENTIAL MARGIN:
*
PERFORATION:
c
Not identified
Present
Through tumour (tumour perforation)
Not involving tumour
c
Defined as a macroscopically visible full thickness defect in the wall
PERITONEUM:
No peritoneal involvement
Tumour invades to the peritoneal surface
Tumour has formed nodule(s) discrete from the tumour mass along the serosal surface
OTHER MACROSCOPIC COMMENT(S)
BLOCK DESIGNATION
MICROSCOPIC
*
HISTOLOGICAL TUMOUR TYPE:
No evidence of residual tumour
Adenocarcinoma (NOS)
Mucinous adenocarcinoma
Signet-ring cell carcinoma
Medullary carcinoma
Serrated adenocarcinoma
Micropapillary carcinoma
Adenoma-like adenocarcinoma
Neuroendocrine carcinoma
Small cell type
Large cell type
Mixed neuroendocrine-non-neuroendocrine neoplasm (MiNEN)
Other (specify)
*
HISTOLOGICAL TUMOUR GRADE:
Not applicable
Low grade (formerly well to moderately differentiated)
High grade (formerly poorly differentiated)
*
EXTENT OF INVASION:
Cannot be assessed
No evidence of primary tumour
High grade dysplasia/non-invasive neoplasia
Tumour invades submucosa
Tumour invades muscularis propria
Invasion into the subserosa or into pericolic or perirectal connective tissues
Invasion onto the surface of the visceral peritoneum
Invasion directly into other structures/organs (specify)
MEASUREMENT OF INVASION BEYOND MUSCLARIS PROPRIA:
Cannot be assessed
Distance of invasion beyond the muscularis propria (nearest 1mm):
mm
INFLAMMATORY CELL INFILTRATE:
*
LYMPHATIC AND VENOUS INVASION
Not identified
Present
Small vessel (lymphatic, capillary or venular)
Large vessel (venous)
Intramural
Extramural
Indeterminate
*
PERINEURAL INVASION
Not identified
Present
*
LYMPH NODE STATUS:
Cannot be assessed
No nodes submitted or found
Not involved
Involved
/
APICAL NODE INVOLVEMENT
Not applicable
Absent
Present
*
TUMOUR DEPOSITS
Not identified
Present
Vascular
Other
Number of tumour deposits:
TUMOUR BUDDING:
Cannot be assessed
Number of tumour buds:
d
Tumour budding score
Bd1 - low budding (0-4 buds)
Bd2 - intermediate budding (5-9 buds)
Bd3 - high budding (> or = 10 buds)
d
After scanning 10 fields on a 20x objective lens, the hotspot field normalised to represent a field of 0.785 mm
2
*
RESPONSE TO NEOADJUVANT THERAPY:
Complete response - no viable cells (score 0)
Near complete response - single cells or rare groups of cancer cells (score 1)
Partial response - residual cancer evident tumour regression (score 2)
Poor or no response - extensive residual cancer with no evident tumour regression (score 3)
Cannot be assessed
*
MARGIN STATUS:
Longitudinal margin status:
Cannot be assessed
Not involved
Estimate distance to closer margin:
mm
Involved
Details (specify):
Circumferential margin status:
Cannot be assessed
Not involved
Distal margin (≥10 mm)
Clearance (specify if <10 mm):
mm
Involved (≤1 mm)
Distance (specify):
mm
By primary tumour
By other (specify)
*
DISTANT METASTASES
Not identified
Present
Specify site(s):
COEXISTING PATHOLOGY:
None identified
Polyp(s)
Synchronous carcinoma
Other (specify)
*
MICROSCOPIC RESIDUAL TUMOUR STATUS:
ADDITIONAL MICROSCOPIC DESCRIPTION
(optional)
COMMENT(S) (optional)
ANCILLARY STUDIES
Neuroendocrine ancillary
Not identified
Present
Neuroendocrine markers (specify):
Ki-67 proliferation index:
%
Mismatch repair (MMR) immunohistochemistry:
Not tested
Not interpretable
MMR Proficient
MMR Deficient
MLH1/PMS2 loss
MSH2/MSH6 loss
MSH6 loss
PMS2 loss
Other (specify)
MMR status by microsatellite instability (MSI) testing:
Not tested
Test failed
MSI-high
MSI-low
MS-stable
Microsatellite comments:
BRAF (V600E) mutation testing:
Not tested
Test failed
Mutated
Wild type
BRAF comments:
MLH1 promoter methylation testing:
Not tested
Test failed
Methylated
Not methylated
Inconclusive
MLH1 comments:
RAS gen mutation testing (KRAS exons 2, 3 or 4, NRAS exon 2, 3 or 4 or RAS mutation):
Not tested
Wild type
Mutated
Ancillary comments:
Laboratory performing test and report number:
*
PATHOLOGICAL STAGING:
TNM Descriptors
(only if applicable)
m - multiple primary tumours
r - recurrent
y - post-therapy
Tumour (T)
TX Primary tumour cannot be assessed
T0 No evidence of primary tumour
Tis Carcinoma in situ, intramucosal carcinoma
T1 Tumour invades submucosa
T2 Tumour invades muscularis propria
T3 Tumour invades through the muscularis propria into pericolorectal tissues
T4a Tumour penetrates to the surface of the visceral peritoneum
T4b Tumour directly invades or is adherent to other organs or structures
Nodes (N)
NX Regional lymph node(s) cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in 1-3 regional lymph nodes
N1a Metastasis in 1 regional lymph nodes
N1b Metastasis in 2-3 regional lymph nodes
N1c Tumour deposit(s) in the subserosa, mesentery, or nonperitonealised pericolic or perirectal tissues without regional nodal metastasis
N2 Metastasis in 4 or more regional lymph nodes
N2a Metastasis in 4-6 regional lymph nodes
N2b Metastasis in 7 or more regional lymph nodes
Metastasis (M)
M0 No distant metastasis
M1 Distant metastasis
M1a Metastasis confined to one organ or site is identified without peritoneal metastasis
M1b Metastases in more than one sites or organ is identified without peritoneal metastasis
M1c Metastases to the peritoneum with or without other organ involvement
*
Residual tumour status:
RX Presence of residual tumour cannot be assessed
R0 No residual tumour
R1 Microscopic residual tumour
R2 Macroscopic residual tumour at the primary cancer site or regional nodal sites
Pathological Staging as per AJCC 8th Ed. (2018)
OVERARCHING COMMENT(S)
DIAGNOSTIC SUMMARY:
None (default)
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At the end of report
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