Preoperative Data Colorectal Cancer Database
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- Emory Carroll
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1 Preoperative Data Please place patient label here Patient Information Patient s Last Name First Middle Initial UR MH MP Birth Date Sex Post Code / / M F ECOG (see codes below) Date of Diagnosis Consultant Medicare Number N/A / / - - Presentation Pathway History Presentation Past History of other cancer(s) Yes No Symptomatic Screen detected Unknown If Yes Yes No Commonwealth FOBT trial Yes No Endometrial Yes No Preoperative Investigations Breast Yes No CEA Yes No Result = Small Bowel Yes No Endorectal US Yes No Stage T = N = Hepatobiliary Yes No MRI Yes No Stage T = N = Urinary tract Yes No Chest CT Yes No Distant Disease Yes No Ovarian Yes No Abdo CT Yes No Distant Disease Yes No Other Yes No CXR Yes No Distant Disease Yes No Type PET Yes No Distant Disease Yes No Date of last incidence / / If History of cancer Height: cm Weight: kg Number of incidences Surgery Age at each incidence Surgery planned Yes No Family Hx of CRC Yes No (1 st degree relatives only) If yes, Date of planned surgery / / Number of 1 st degree relatives Potential Tissue Bank Donor Yes No Age at each incidence,, Comorbidities If No, reason Diabetes Yes No Doctors discretion Yes No If yes Type 1 Type 2 insulin req Type 2 Distant disease Yes No Hx of smoking Yes No Medically unfit Yes No If Yes, current smoker* Yes No Patient declined Yes No Crohns Disease Yes No Other Yes No Ulcerative Colitis Yes No * Patient having smoked cigarettes within one month of this visit Grade ECOG 0 Fully active, able to carry on all pre-disease performance without restriction 1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work 2 Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours 3 Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours 4 Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair If you have any queries regarding this data collection form then please do not hesitate to contact Michael Harold on ext (Monday-Friday 9am to 5pm) Record Status Date Entered Complete Incomplete / / Officers Initials/Signature
2 Operation Report Surgery Details Date of Surgery Operator Assistant Urgency / / Elective Emergency ASA Score: N/A Private insurance Yes No Tumour Site (If multiple tumours designate by number) Colon Appx Hepatic flexure Descending colon Caecum Transverse colon Sigmoid colon Ascending colon Splenic flexure Rectosigmoid Rectum Upper third Middle third Lower third Cm from anal verge (rigid sigmoidoscopy) cm Tumour Staging Tumour 1 Tumour 2 Tumour 3 Primary tumour colon Adherent Yes No N/A If yes, to Adherent Yes No N/A If yes, to Adherent Yes No N/A If yes, to Primary tumour rectum Mobile Tethered Mobile Tethered Mobile Tethered Fixed N/A Fixed N/A Fixed N/A Distant metastases None Peritoneal Hepatic Non regional Lymph Nodes Lung Brain Bone Other If Hepatic Right Left Bilobar Bx Yes No Surgery Method Open Laparoscopic Laparoscopic abandoned Other Operation performed TME Right Hemicolectomy High AR TME performed: Yes No N/A Extended Right Hemicolectomy Low AR If yes, Package intact: Yes No Left Hemicolectomy Ultra Low AR Bowel Management N/A Sigmoid colectomy APR Rectal washout Yes No Total colectomy Hartmann s Testing anastomoses Yes No Sub total colectomy Local excision Colonic lavage (on table) Yes No Proctocolectomy Laparotomy only Transverse colectomy Stoma Fashioned Other None Loop ileostomy Loop colostomy End ileostomy End colostomy Tumour 1 Tumour 2 Tumour 3 Anastomosis method Handsewn N/A Handsewn N/A Handsewn N/A Staple Staple Staple Anastomosis type End-End N/A End-End N/A End-End N/A End-Side Side-Side End-Side Side-Side End-Side Side-Side Private Pathology sent to: RMH Other
3 Surgery Outcomes Admission and Discharge Date of admission Delay in discharge If yes, reason Surgical complications / / Yes No Medical complications Date of discharge Social / / Other Transfusion Transfused Yes No Surgical Complications Yes No Abdominal/pelvic collection Superficial wound dehiscence Anastomotic leak Radiological Clinical Deep wound dehiscence Enterocutaneous fistula Prolonged ileus Wound infection Small bowel obstruction Septicemia Urinary retention Primary cause of sepsis intra-abdominal Ureteric injury chest UTI Incontinence line related endocarditis Splenectomy Organism grown Yes No Other Type Medical Complications Yes No DVT/PE Acute confusional state Cardiac Pressure sores Chest infection Other Pneumothorax Type Return to Theatre Returned to theatre Yes No Date returned / / Reason: Death Inpatient Death Yes No Death Date / / Cause of Death Due to cancer Other cause, cancer not present Due to post-op complications Contribution of cancer to death unknown Other cause, cancer present Adjuvant Therapy Adjuvant therapy offered If No, reason If Yes Patient accepted Yes No Early Stage Comorbidity Patient declined Late Stage Patient Age Preop Chemo Postop Chemo Preop Radiation Postop Radiation Oncologist
4 Pathology *Please complete one form per tumour Tumour Site: Staging Nodes T 0 is X Nodes examined Nodes positive N X Differentiation M 0 1 X Undifferentiated Poor Poor-Moderate ACPS A B C D O X Y Moderate Moderate-Well Well N/A Metastases Microscopic type Biopsy confirmed distant metastases Yes No Adenocarcinoma Other Resected metastases Yes No Mucinous If yes, Peritoneal Yes No Yes No Not reported N/A Liver Yes No Lymphovascular invasion Other Yes No Yes No Not reported N/A Margins Inflammatory infiltrate Distal Involved Not involved Not reported Present Absent Not reported N/A Distance mm Polyps Radial Involved Not involved Not reported N/A Polyps present Yes No Number Distance mm Type Tubular adenoma Tumour Size Tubulovillous adenoma Villous adenoma Size of tumour x x mm Serrated adenoma Mixed polyp Pathologic response Hyperplastic polyp Other (Preop rectal Complete response Major response Immunohistochemistry and MSI Rx only) Progressive disease Other MSI MSS MSI-L MSI-H N/A MLH1 Present Absent Equivocal Necrosis MSH2 Present Absent Equivocal Necrosis (if preop tx) Present Absent Not reported MSH6 Present Absent Equivocal DEFINITIONS Staging T Primary Tumour Staging 0 No evidence of primary tumour is Carcinoma in situ: intraepithelial or invasion of the lamina propria 1 Tumour invades submucosa 2 Tumour invades muscularis propria 3 Tumour invades through the muscularis propria into the subserosa, or into perirectal tissues 4 Tumour directly invades other organs or structures, and/or perforates visceral peritoneum X Primary tumour can not be assessed Staging N Staging M Regional lymph nodes staging Distant metastases staging 0 No regional lymph node metastases 0 No distant metastases 1 Metastases in 1 to 3 regional lymph nodes 1 Distant metastases 2 Metastases in 4 or more regional lymph nodes X Distant metastases can not be assessed X Regional lymph nodes can not be assessed ACPS Australian ClinicoPathological Stage A The carcinoma has spread into the bowel wall but not beyond the muscularis propria. There are no lymph node metastases, nor distant metastases. B The carcinoma has spread beyond the muscularis propria into the adjacent tissues in continuity or into adjacent organs. There are no lymph node metastases, nor distant metastases. C The carcinoma may have varying spread into or through the bowel wall but one or more lymph nodes contain cancer. There are no distant metastases. D Palliative resection or operation performed, or clinical or microscopic evidence of extensive spread of the carcinoma locally through the bowel wall or of distant metastases preventing operation. O Carcinoma is confined to the mucosa in a patient who has undergone a bowel resection. X A local excision of the carcinoma is done, without lymphadenectomy Y Pathological details are, for some reason, not known.
5 Adjuvant Therapy* *To Be Filled Out For All Patients Undergoing Surgery Treatment Offered Adjuvant treatment offered If No, reason If Yes Patient accepted Yes No Early stage Comorbidity Patient declined Late stage Patient Age Adjuvant Chemotherapy (Please use codes below) Preop Yes No Postop Yes No Start Chemotherapy Date / / / / Regimen 1 Planned duration (weeks) Initial Dose reduced% & reason 2 % % Subsequent Dose Reduction Yes No Yes No Date / / / / Agents reduced 1 Toxicity type 3 % reduction % % 2 nd Subsequent Dose Reduction Yes No Yes No Date / / / / Agents reduced Toxicity type 3 % reduction Stop Chemotherapy Date / / / / Reason for stopping 4 If due to Toxicity, type 3 Adjuvant Radiotherapy Preop Yes No Postop Yes No Start Date / / / / Dose 50.4 Gy 25 Gy Other 50.4 Gy 25 Gy Other Fractions 28 5 other 28 5 other Fields Standard other Standard other Completed Yes No Yes No If No, due to 4 Codes 1 Regimen / Agents 2 Dose reduction reason 3 Toxicity type 4 Reason for stopping FU = 5FU Ag = Age HA = Hematologic Toxicity CT = Completed planned Rx XE = Capecitabine CM = Co-morbidity D = Diarrhea PD = Progressive disease OX = Oxaliplatin PTx = Previous toxicity N/V = Nausea/Vomiting TX = Toxicity IR = Irinotecan HFS = Hand/Foot syndrome RQ = Patient request BA = Bevacizumab PN = Neuropathy DT = Death Toxicity CE = Cetuximab OT = Other DO = Death Other LE = Leucovorin ST = Stomatitis OT = Other OT = Other
6 ROUTINE FOLLOW UP To be completed at each routine follow-up visit by the surgeon or oncologist Date of visit / / / / / / / / / / / / / / / / Evidence of Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No recurrence* Colonoscopy CEA CT Next appointment in not If patient has recurrence/metastases please fill out Summary at time of Recurrence/Treatment of Metastases form next visit not not not not not not not If 1 st follow up visit, was the patient readmitted >30 days post operatively Yes No
7 Summary at time of Recurrence/Treatment of Metastases For patients with complete resection, please fill out a new form at time of further relapse RECURRENCE SUMMARY Date detected / / Definite Biopsy Yes No Stage IV at diagnosis Yes No Possible Please tick all that apply Loco/regional recurrence Anastomosis Regional nodes Peritoneum Local Omentum Distant metastases Liver Brain Lymph nodes Lung Bone Other Method of detection Clinical Colonoscopy (1 st detected) CT CEA Result: Within normal range Yes No PET Other TREATMENT PLAN Yes No if No reason Poor performance status Co-morbidities Age Patient declined Asymptomatic Surgical resection Neoadjuvant Chemotherapy (NA) SIRT Chemotherapy Radiotherapy Other TREATMENT GIVEN ( * Please use codes below) Chemotherapy (please circle) NA 1 st 2 nd 3 rd 4 th NA 1 st 2 nd 3 rd 4 th NA 1 st 2 nd 3 rd 4 th NA 1 st 2 nd 3 rd 4 th Start Chemotherapy Date / / / / / / / / Regimen 1 Initial Dose reduced% & reason 2 % % % % Subsequent Dose Reduction Date / / / / / / / / Agents reduced Reason 5 % reduction % % % % Stop Chemotherapy Date / / / / / / / / Reason for stopping 3 Best Response 4 Surgical resection Date / / / / / / / / Site Number of metastases Result 6 Codes 1 Regimen / Agents 5 Subsequent dose reduced 4 Best response 3 Reason for stopping FU = 5FU HA = Hematologic Toxicity CR = complete response CT = Completed planned Rx XE = Capecitabine D = Diarrhea PR = partial response PD = Progressive disease OX = Oxaliplatin N/V = Nausea/Vomiting SD = stable disease TX = Toxicity IR = Irinotecan HFS = Hand/Foot syndrome PD = progressive disease RQ = Patient request BA = Bevacizumab PN = Neuropathy NE = not evaluable OT = Other CE = Cetuximab ST = Stomatitis 2 Dose reduction reason 6 Result of Surgery LE = Leucovorin OT = Other Ag = Age R0 = Complete excision MC = Mitomycin C CM = Co-morbidity R1 = Microscopic residual disease OT = Other PTx = Previous toxicity R2 = Macroscopic residual disease
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