LOINC. Clinical information. RCPA code. Record if different to report header Operating surgeon name and contact details. Absent.

Transcription

1 Complete as narrative or use the structured format below Clinical information Record if different to report header Operating surgeon name and contact details Through tumour prior to surgery Through tumour during surgical mobilisation Nature of perfoation Perforation Away from tumour Clinical obstruction Cecum structure Caecum Ascending colon structure Ascending colon Blue italic text = Coentary / Special coents to assist with reporting Structure of right colic flexure Hepatic flexure Transverse colon structure Transverse colon Structure of left colic flexure Splenic flexure Descending colon structure Descending colon Tumour location Sigmoid colon structure Sigmoid colon Structure of rectosigmoid junction Rectosigmoid junction Rectum structure Rectum (3rd Ed Indicate each other site Note: Synchronous tumours should be reported separately - this identifies the presence of other synchronous tumours for which separate reports will be submitted For synchronous tumours indicate each other site cm Distance from the anal verge Right hemicolectomy Right hemicolectomy Extended right hemicolectomy Extended right hemicolectomy Transverse colectomy Transverse colectomy Left colectomy Left hemicolectomy Low anterior resection of rectum and total excision of mesorectum Anterior resection (High, Low, Ultralow) Abdominoperineal resection of rectum Abdominoperineal resection Type of operation Proctocolectomy Proctocolectomy Total colectomy with ileorectal anastomosis Total colectomy with ileorectal anastomosis Hartmann operation, rectal resection Hartmann s procedure Other procedure(s) Patient received short course of preoperative radiotherapy Short course Patient received long course of preoperative radiotherapy Long course Yes Preoperative radiotherapy Patient did not receive preoperative radiotherapy No Surgeon's opinion on the existence of local residual cancer postsurgery Involvement of adjacent organs New primary Local recurrence of malignant tumour of rectum Regional (local) recurrence Distant metastasis present New primary cancer or recurrence, describe Details: Distant metastases Other relevant details Pathology Accession number RCPA - SPIA Report Information Model v1.0.ap - 5/01/ Mindjet

2 Blue italic text = Coentary / Special coents to assist with reporting (3rd Ed LN-RCPA Specimen length Cecum structure Caecum Ascending colon structure Ascending colon Structure of right colic flexure Hepatic flexure Transverse colon structure Transverse colon Structure of left colic flexure Splenic flexure Tumour site Descending colon structure Descending colon Sigmoid colon structure Sigmoid colon Structure of rectosigmoid junction Rectosigmoid junction Rectum structure Rectum Maximum tumour diameter Distance of tumour to the nearer proximal or distal 'cut end' Distance of tumour to the nonperitonealised circumferential margin Tumour perforation Entirely above Entirely above Astride Astride Relationship to anterior peritoneal reflection Entirely below Entirely below Intactness of mesorectal specimen incomplete Incomplete (grade 1) Mesorectal specimen nearly completely intact Nearly complete (grade 2) Intactness of mesorectum Mesorectal specimen completely intact Complete (grade 3) Tumour invades to the peritoneal surface Tumour invades to the peritoneal surface Tumour has formed nodule(s) discrete from the tumour mass along the serosal surface Peritoneum No sample received Not received Specimen received Received Record cassette number/identification LN-RCPA Cassette number Lymph nodes Record number of nodes per Number of lymph nodes per cassette if received cassette i.e. n in cassette n Number of lymph nodes per cassette Provide a polyp suary (text) Polyps Polyp suary Other macroscopic coents Nature and site of all blocks RCPA - SPIA Report Information Model v1.0.ap - 5/01/ Mindjet

3 Adenocarcinoma, NOS Adenocarcinoma, no subtype 8140/3 Cribriform comedo-type adenocarcinoma Comedocarcinoma, noninfiltrating 8201/3 Medullary carcinoma, NOS Medullary carcinoma 8510/3 Micropapillary carcinoma Micropapillary carcinoma 8265/3 Colloid carcinoma Mucinous adenocarcinoma 8480/3 Tumour type Serrated adenocarcinoma Serrated adenocarcinoma 8213/3 Signet ring cell carcinoma Signet ring cell carcinoma 8490/3 Adenosquamous carcinoma Adenosquamous carcinoma 8560/3 Spindle cell carcinoma, NOS Spindle cell carcinoma 8032/3 Squamous cell carcinoma, NOS Squamous cell carcinoma 8070/3 Undifferentiated carcinoma Carcinoma, undifferentiated 8020/3 Low grade Low grade histologic differentiation Histological grade High grade High grade histologic differentiation pt pt1: Tumour invades submucosa (colon/rectum) pt pt2: Tumour invades muscularis propria (colon/rectum) Maximum degree of local invasion into or through the bowel wall pt3 pt4a pt3: Tumour invades through the muscularis propria into the subserosa or into non-peritonealized pericolic or perirectal tissues (colon/rectum) pt4a: Tumour directly invades other organs or structures (colon/rectum) pt4b pt4b: Tumour penetrates visceral peritoneum (colon/rectum) Involved Distal Proximal Large intestine, distal surgical margin, involved by tumor Anal, distal surgical margin involved by tumor Large intestine, proximal surgical margin, involved by tumor Anal, proximal surgical margin involved by tumor Large intestine, distal surgical margin not involved by tumor Distal Anal, distal surgical margin not involved by tumor Involvement of the proximal or distal resection ('cut end') margins Not involved Proximal Large intestine, proximal surgical margin not involved by tumor Anal, proximal surgical margin not involved by tumor Record clearance (if the margin is less than 10 ) in Distance of tumor from closest distal margin if not involved Clearance Distance of tumor from closest proximal margin Blue italic text = Coentary / Special coents to assist with reporting Clearance 10 LN-RCPA Involved Involved Not involved Not involved Status of the nonperitonealised circumferential margin if not involved Microscopic clearance (3rd Ed Site Site [1..n] - record text (site) Record site(s) and number of positive lymph nodes / total number of lymph nodes from this site e.g. nn / nn Lymph node involvement Number of positive nodes Number of positive: Total number of nodes Isolated extra-mural tumour deposits Apical node involvement Not applicable Not applicable Intramural venous invasion not identified Intramural vein invasion Venous (large vessel) intramural invasion by tumour present (venous) Lymphatic (small vessel) intramural invasion by tumour present (small vessel) Extramural venous invasion not identified Venous and small vessel invasion Extramural vein invasion Venous (large vessel) extramural invasion by tumour present (venous) Lymphatic (small vessel) extramural (small vessel) invasion by tumour present Lymphatic (small vessel) invasion by tumour not identified Small vessel invasion , extensive Lymphatic (small vessel) invasion by tumour present Extensive lymphatic (small vessel) invasion by tumor present Perineural invasion by tumour not identified Perineural invasion , extensive Perineural invasion by tumour present Extensive perineural invasion by tumour present Histologically confirmed distant metastases Site [1..n] None noted Nil Ulcerative colitis Ulcerative colitis Ulcerative colitis with dysplasia Ulcerative colitis with dysplasia Ulcerative colitis without dysplasia) Ulcerative colitis without dysplasia Crohn's disease Crohn's disease Relevant coexistent pathological abnormalities Crohn's disease with dysplasia Crohn's disease without dysplasia Crohn's disease with dysplasia Crohn's disease without dysplasia Other Describe Polyp of intestine Polyps Polyp details Describe type, number, polyposis syndrome criteria met, etc Other Microscopic residual tumour status (completeness of resection) LN-RCPA No prior treatment No prior treatment Grade 0 (complete treatment) Complete therapeutic response No viable cancer cells Response to neoadjuvant therapy Grade 1 (moderate response) Single cells or small groups of cancer cells Minimal therapeutic response Grade 2 (minimal response) Residual cancer outgrown by fibrosis Grade 3 (poor response) Poor response to treatment Minimal or no tumour kill; extensive Microscopic coents RCPA - SPIA Report Information Model v1.0.ap - 5/01/ Mindjet

4 Blue italic text = Coentary / Special coents to assist with reporting (3rd Ed MLH Normal iunohistochemical staining Loss of iunohistochemical staining PMS Normal iunohistochemical staining Loss of iunohistochemical staining Mismatch repair enzymes MSH Normal iunohistochemical staining Loss of iunohistochemical staining MSH Normal iunohistochemical staining Loss of iunohistochemical staining Coents Unstable Unstable status Stable Stable Microsatellite instability (MSI) Coents Mutated Mutated phenotype Wild type Wild type phenotype BRAF (V600E mutation) Coents Mutated Mutated phenotype KRAS exons 2,3 or 4; NRAS exons 2,3 or 4 or RAS mutation Wild type Wild type phenotype RAS gene mutation testing Coents RCPA - SPIA Report Information Model v1.0.ap - 5/01/ Mindjet

5 Blue italic text = C oentary / Spec ial c oents to as s is t with reporting (3rd Ed ptx pt ptx category pt0 category ptis pt ptis category pt1 category T classification pt pt2 category pt pt3 category pt4a pt4a category pt4b pt4b category pnx pnx category pn pn0 category pn pn1 category pn1a pn1a category N classification pn1b pn1b category pn1c pn1c category pn pn2 category pn2a pn2a category Tumour stage (AJCC 2010) pn2b pn2b category cm pm0 category cm pm1 category M classification cm1a pm1a category cm1b pm1b category Stage 0 I Stage IIA IIB Stage 2A Stage 2B IIC Stage 2C Stage group IIIA Stage 3A IIIB Stage 3B IIIC Stage 3C IVA Stage 4A IVB Stage 4B Year of publication and edition of cancer staging system R0 : Complete resection, margins histologically negative, no residual tumour left after resection (primary tumour, regional nodes) Residual tumour stage R0 Residual tumour status R1 : Incomplete resection, margins histologically involved, microscopic tumour remains after resection of gross Residual tumour stage R1 disease (primary tumour, regional nodes) R2: Incomplete resection, margins macroscopically involved or gross disease remains after subtotal resection Residual tumour stage R2 (e.g. primary tumour, regional nodes or liver metastasis) Specimen type Tumour size Diagnostic suary , include: Tumour type Tumour stage Completeness of excision New primary Indeterminate Indeterminate New primary cancer or recurrence OR Recurrent tumour Regional (local) recurrence Distant metastasis present Distant metastases , describe Overarching coent RCPA - SPIA Report Information Model v1.0.ap - 10/01/ Mindjet