LP registration. e icccucclocó&ucccoc[sccoccfcgcceccucocuclc

Transcription

1 CO C C 0 1. Patiek data I( Natiorialnumber R Nanie LP registration....coc mocciiiccococomccoccocmccociocccccocooc... OCCCOOCUCCCCOOCCOOcC0.0 ocomarscnuonagapacuotoustlencomeencucenacteuentio. First name' Date of fo,irth (cid/mrt-gym) -.caccctee caccecizaues peccemcc6 enosea cs nem Zi p code P, Sex Mutuali R"-t e icccucclocó&ucccoc[sccoccfcgcceccucocuclc 2. Hospital data Name llospital mro dOCCUO... e.«...uocuctepooman eacioc.ocenamcsamiloccocceent curccocioccencionecinuoiscce...ncco RH ) El restonsible physician CM -registration: _ u Yes date (dclimm/yyyy) c). 3 Past history registration Previous urological condition: o No Q o Yes erv If yes o TURF (BN) o Urethral stenosis o Urinary stones o Urinary infections o Other (SPecifY):m Unknown Previous medical treatrnent for urological disease: o No nsv Yes [[yes R:"!: o 5a-reductase inhibitors (dustasteride-finasteride) c) Other (SI)ecifY): o Unknown Food suppternent for prostate cancel- preve,ntion: o Yes '" If Yes, \A-lich: CCCOCOCCOCCOCOCCCo El No "' Unknown mn CCOCCCOC OCOOC CCCCCO Ll C. 00COCO0

2 4. Family liis-tory for prostaie cancer (first degree r et a t iv e) u Yes "'..., If Yes: date at diagnosis. )1 1:1- (il 11Z1-1) u u No 1`") Unknown age at diagnosis occo du..... O Diagnosis Clinical stage (TNM 2002) Surnmary etnm stage: t i f I r T OCIOCCEODEOMM UPLCCO Tumor localisation u right u left bilateral u u r kn oven Metastases Yes El basis u id u apex u diffuse u unknown PSA data: Initial PSA: o Value (ng/ml) REQ e COO.... REL) o Date o u PSA at biopsy: o Value (ng/m1) R Pa«.() o Date Prostate biopsy: Date Number of biopsy cores C.O6OCCOGGIC005CCSCO.MCGDOC Number of positive cores El Detail for individual core: Gore o Gleason score: a v vore o Gleason score: ce na c....,...

3 Core R3 o Gleason score: Core R4 '): o Gleason. score: c... Core R5 0 Gleason C C (Core R_6)'" o Gleason score: o cancer CoreoL IG\I"l Gleason si)! score: Core L2 '1' ( "'"E1). o Gleason score: Core0L3 s0ii R I- `''' s:rtet:: Gleason Core L4 t '` o Gleason score: o Iength cancer: CoreL5 0Giea:o:s:0;e: \ `t i ri 1 : o Iength cancer: (Core L6 ) \01,:n.)! o Gleason score: o Iength cancer: 6. Urogenitall function before treatment (Questionaires ICIQIIEF, EORTC 13R25, QLQ-C30) o Urinary function : ICIQ score k"' Sexual function : IIEF score EI Quality of life : EORTC PR 25 score and/or QLQ-C30 score R`<-'. 7. OPERATIVE 2-ATA EDITT-IY -mam Hospitalisation number of surge,uy (dc1/1.-131dyyyy) 0000CC0.0{ ,C

4 Details of RALP-surgery Nerve sparing u Yes: If yes O bilateral O unilateral right o unilateral left o unknown Unknown Lymphadenectomy E1 0 If yes RI o iimited O extended O unknown No u Unknown Blood loss (m1) Cornplications ( s): Ei Yes (d1opeto\\,1) ci Unknown cc Disposables used: please enter number of units used u Large needle driver:... EI Hot shears:... RF'Q u Maryland bipolar forceps:... u Prograsp forceps:... RI-Q u Other R1«Q: (number and specification) 3. Postoperative dat oln Postoperative death u Yes Date of death (dd/mm/yyyy) Cause of death Rr'Q. / unknown / unknown Postoperative niorbidity mffitiscied. dropclown Transfusions : number of units Other Discharge date (ddhurrdyyyy) Q. Pathologicall data Surnmary ptnivi stage TNIVI 2002) 1' LQ: p T N Ivi

5 Details of pathological report: Gleason score : Dominant pattern :...( ) Secondary pattern u1(-) T (). O X 0 1 2a -2b 2c 3a - 3b 4 % tumor volume/total volume... N ' X 0 1 number of pos nodes / total number of nodes m ci R X 0 1.(11 1è 1 (l si 1.) D <" unknown o if positive section margin : location and length in mm I):.Adjuvant treatnief: (-) u Radiotherapy R I O No O total dose. O number of fractions l`r O start date RI-\):... COOISO... OCE CC... O end date u Hormonal therapy Ri No O LFIRI-1 I O Anti-androgen l'') O Total androgen blokkade ) O stad date RL `j O end date l`` ' ) 9. Follow-up month / 3 month / 12 month 1 24 month date u PSA (Value (ng/ml)) u Urinary function : ICIQ score '''') : u Sexual function : IIEF score RE'). u Quality of life : EORTC PR 25 score l'"). and/or QLQ-C30 score ""). f r.,q u Complications ' : dropdo,.vri lis] Late adjuvant er Saivage treatment (> 3 mcmiths after surgery ) Radiotherapy o No o Yes O total dose (s1: O number of fractions O start date''''1. ece O end date ( s'

6 n Hormonal therapy o No O LHRH R1-`) O Anti-androgen ( c) O Total androgen blokkade OOOOOO O start date RIE() O end date k r( ) Death No, alive at (date) RI RH) If Yes: Date (dclim m/yyyy) 1:1 Cause (check) O Prostatecancer related O Cancer related R L () O Unknown [1.2 `.) O Other (specify) * 0a [WOCCI6C CG... OCIZEO[ C CCIS