Cancer Synoptic Report (Colon/Rectum Resection)

Patient Name: [Patient full name]

MRN: [Medical record number]

Date of Birth: [Date of birth]

Accession Number: [Accession number]

Date of Collection: [Specimen collection date]

Date of Report: [Report date]

Pathologist: [Pathologist name, credentials]

Submitting Clinician: [Clinician name]

Diagnosis

[Brief narrative diagnosis summarizing specimen and key findings] (One-line summary per specimen; refer to synoptic block for staging and prognostic parameters.)

Synoptic Report: Colon/Rectum Resection

Specimen - Procedure: [Right hemicolectomy / Left hemicolectomy / Low anterior resection / Abdominoperineal resection / Total colectomy / Segmental resection / Other (specify) / Not specified]

Specimen - Macroscopic evaluation of mesorectum: [Complete / Near complete / Incomplete / Cannot be determined (reason)] (Rectal specimens only; omit for non-rectal resections)

Tumor - Tumor site: [Cecum / Ascending colon / Hepatic flexure / Transverse colon / Splenic flexure / Descending colon / Sigmoid colon / Rectosigmoid junction / Rectum / Colon, NOS (reason)]

Tumor - Rectal tumor location: [Above anterior peritoneal reflection / Below anterior peritoneal reflection / Straddles anterior peritoneal reflection / Not specified] (Rectal primaries only; omit for non-rectal tumors)

Tumor - Histologic type: [Adenocarcinoma / Mucinous adenocarcinoma / Signet ring cell carcinoma / Medullary carcinoma / Adenosquamous carcinoma / High-grade neuroendocrine carcinoma / Mixed carcinoma (specify components) / Other (specify)]

Tumor - Histologic grade: [Well differentiated / Moderately differentiated / Poorly differentiated / Undifferentiated / Cannot be assessed (reason)]

Tumor - Tumor size (greatest dimension): [cm] (If multiple foci, state size of largest; summarize additional foci in Comment.)

Tumor - Tumor extent (deepest invasion): [Invades submucosa / Invades muscularis propria / Invades through muscularis propria into pericolorectal tissues / Invades visceral peritoneum (serosa) / Directly invades adjacent organ/structure (specify)]

Tumor - Macroscopic tumor perforation: [Present / Absent / Cannot be determined (reason)]

Tumor - Lymphovascular invasion: [Not identified / Present (specify: small vessel / large vessel / intramural / extramural) / Cannot be determined (reason)]

Tumor - Perineural invasion: [Not identified / Present / Cannot be determined (reason)]

Tumor - Tumor budding: [Low / Intermediate / High / Cannot be determined (reason) / Not applicable] (Optional: include bud count per 0.785 mm². Mark Not applicable for histologic variants where budding does not apply.)

Tumor - Treatment effect: [No known presurgical therapy / Complete response / Near complete response / Partial response / Poor or no response] (Include only if neoadjuvant therapy was administered; use institutional regression grading system.)

Margins - Margin status (invasive carcinoma): [Negative (all margins uninvolved) / Positive (specify margin)]

Margins - Closest margin: [Name of closest margin]

Margins - Distance to closest margin: [mm / >10 mm]

Margins - Distance to radial (circumferential) margin: [mm] (Rectal specimens only)

Margins - Distance to distal margin: [mm] (Rectal specimens only)

Margins - Margin status (dysplasia/in situ disease): [Negative / Positive (specify margin) / Not applicable] (Include only if high-grade dysplasia or intramucosal carcinoma is present at a margin separate from invasive carcinoma.)

Regional Lymph Nodes - Regional lymph node status: [No lymph nodes submitted / Negative for tumor / Positive for tumor]

Regional Lymph Nodes - Number of lymph nodes examined: [integer]

Regional Lymph Nodes - Number of lymph nodes positive: [integer]

Regional Lymph Nodes - Tumor deposits: [Not identified / Present (number: integer)] (Deposits with identifiable vessel wall should be classified as venous invasion.)

Regional Lymph Nodes - Isolated tumor cells (ITCs): [Not identified / Present] (If present, document detection method and pN assignment per institutional policy.)

Distant Metastasis - Pathologically confirmed metastasis: [Present (specify site) / Not applicable (no distant metastatic tissue submitted)] (Include only if distant metastatic tissue was submitted and evaluated.)

Pathologic Stage Classification (pTNM) - pT category: [pT value] (Apply prefix as applicable: y for post-neoadjuvant, r for recurrent, m for multiple primaries.)

Pathologic Stage Classification (pTNM) - pN category: [pN value] (Include descriptors as applicable, e.g., (i+), (sn).)

Pathologic Stage Classification (pTNM) - pM category: [pM value / Not applicable] (Report only if pathologically confirmed metastasis was examined. Do not assign overall stage group.)

Additional Findings

[Other pathologic findings] (e.g., adenomas with number and type, sessile serrated lesions, diverticulosis, IBD-related changes. Omit section if no significant additional findings.)

Comment

[Explanatory notes affecting interpretation or staging] (Use for caveats, margin nuances, correlation recommendations, staging limitations, or pending studies. Omit section if no comment needed.)

Special Studies / Biomarkers

• MMR IHC: [Proficient (intact MLH1/PMS2/MSH2/MSH6) / Deficient (specify lost protein)] (Include antibodies tested and internal control adequacy.)
• MSI: [MSI-High / MSI-Low / Microsatellite stable / Not performed] (Include method: PCR or NGS.)
• RAS (KRAS/NRAS): [No pathogenic variants detected / Pathogenic variant detected (specify gene, exon, variant)]
• BRAF V600E: [Detected / Not detected / Not performed]
• HER2: [Negative / Equivocal / Positive] (Include method and scoring.)
• Other studies: [Additional biomarkers, methods, and results] (If reported in separate addendum, reference here.)

(If any studies are pending, note in Comment section and issue addendum when finalized.)