Complete as narrative or use the structured format below 55752-0 17.02.28593 Clinical information 22027-7 17.02.30001 Record if different to report header Operating surgeon name and contact details 52101004 Through tumour prior to surgery Through tumour during surgical mobilisation 84874-7 17.02.28296 Nature of perfoation 84875-4 17.02.28289 Perforation Away from tumour 52101004 84876-2 17.02.28292 Clinical obstruction 32713005 Cecum structure Caecum 9040008 Ascending colon structure Ascending colon Blue italic text = Coentary / Special coents to assist with reporting 48338005 Structure of right colic flexure Hepatic flexure 485005 Transverse colon structure Transverse colon 72592005 Structure of left colic flexure Splenic flexure 33725-3 17.02.28347 32622004 Descending colon structure Descending colon Tumour location 60184004 Sigmoid colon structure Sigmoid colon 49832006 Structure of rectosigmoid junction Rectosigmoid junction 34402009 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. 84877-0 17.02.28346 For synchronous tumours indicate each other site cm 33748-5 17.02.28335 Distance from the anal verge 235326000 Right hemicolectomy Right hemicolectomy 17.02.28592 174071004 Extended right hemicolectomy Extended right hemicolectomy 26925005 Transverse colectomy Transverse colectomy 82619000 Left colectomy Left hemicolectomy 448474003 Low anterior resection of rectum and total excision of mesorectum Anterior resection (High, Low, Ultralow) 265414003 Abdominoperineal resection of rectum Abdominoperineal resection 29300-1 17.02.27919 Type of operation 174059005 Proctocolectomy Proctocolectomy 820571000168101 Total colectomy with ileorectal anastomosis Total colectomy with ileorectal anastomosis 16564004 Hartmann operation, rectal resection Hartmann s procedure 29554-3 17.02.30020 Other procedure(s) 813751000168103 Patient received short course of preoperative radiotherapy Short course 813761000168101 Patient received long course of preoperative radiotherapy Long course Yes 81167-9 17.02.28283 Preoperative radiotherapy 814131000168105 Patient did not receive preoperative radiotherapy No 81169-5 17.02.28295 Surgeon's opinion on the existence of local residual cancer postsurgery 81168-7 17.02.28336 Involvement of adjacent organs New primary 314966008 Local recurrence of malignant tumour of rectum Regional (local) recurrence 399409002 Distant metastasis present 21983-2 17.02.28337 New primary cancer or recurrence, describe 84878-8 17.02.30002 Details: Distant metastases 11329-0 17.02.28301 Other relevant details 57723-9 17.02.28300 Pathology Accession number RCPA - SPIA Report Information Model v1.0.ap - 5/01/2017 - Mindjet
Blue italic text = Coentary / Special coents to assist with reporting (3rd Ed LN-RCPA-00066 17.02.28342 Specimen length 32713005 Cecum structure Caecum 9040008 Ascending colon structure Ascending colon 48338005 Structure of right colic flexure Hepatic flexure 485005 Transverse colon structure Transverse colon 72592005 Structure of left colic flexure Splenic flexure 33725-3 17.02.27931 Tumour site 32622004 Descending colon structure Descending colon 60184004 Sigmoid colon structure Sigmoid colon 49832006 Structure of rectosigmoid junction Rectosigmoid junction 34402009 Rectum structure Rectum 21889-1 17.02.28360 Maximum tumour diameter 81175-2 17.02.28359 Distance of tumour to the nearer proximal or distal 'cut end' 81176-0 17.02.28358 Distance of tumour to the nonperitonealised circumferential margin 52101004 84879-6 17.02.27963 Tumour perforation 814031000168109 Entirely above Entirely above 813821000168100 Astride Astride 84880-4 17.02.28362 Relationship to anterior peritoneal reflection 813891000168103 Entirely below Entirely below 17.02.27906 408659008 Intactness of mesorectal specimen incomplete Incomplete (grade 1) 408658000 Mesorectal specimen nearly completely intact Nearly complete (grade 2) 33730-3 17.02.27967 Intactness of mesorectum 408657005 Mesorectal specimen completely intact Complete (grade 3) 817291000168105 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 66111-6 17.02.28369 Peritoneum 281266006 No sample received Not received 440622005 Specimen received Received Record cassette number/identification LN-RCPA-00103 17.02.30016 Cassette number 66112-4 17.02.28372 Lymph nodes Record number of nodes per Number of lymph nodes per cassette if received cassette i.e. n in cassette n 44621-1 17.02.28375 Number of lymph nodes per cassette 52101004 Provide a polyp suary (text) 33745-1 84881-2 17.02.28376 Polyps 17.02.28379 Polyp suary 22634-0 17.02.28380 Other macroscopic coents 81178-6 17.02.28381 Nature and site of all blocks RCPA - SPIA Report Information Model v1.0.ap - 5/01/2017 - Mindjet
Adenocarcinoma, NOS 35917007 Adenocarcinoma, no subtype 8140/3 Cribriform comedo-type adenocarcinoma 78197004 Comedocarcinoma, noninfiltrating 8201/3 Medullary carcinoma, NOS 32913002 Medullary carcinoma 8510/3 Micropapillary carcinoma 450895005 Micropapillary carcinoma 8265/3 Colloid carcinoma 72495009 Mucinous adenocarcinoma 8480/3 Tumour type 17.02.27974 84882-0 Serrated adenocarcinoma 450948005 Serrated adenocarcinoma 8213/3 Signet ring cell carcinoma 87737001 Signet ring cell carcinoma 8490/3 Adenosquamous carcinoma 59367005 Adenosquamous carcinoma 8560/3 Spindle cell carcinoma, NOS 65692009 Spindle cell carcinoma 8032/3 Squamous cell carcinoma, NOS 28899001 Squamous cell carcinoma 8070/3 Undifferentiated carcinoma 38549000 Carcinoma, undifferentiated 8020/3 Low grade 399415002 Low grade histologic differentiation Histological grade 17.02.27988 33732-9 High grade 399611001 High grade histologic differentiation pt1 373200003 pt1: Tumour invades submucosa (colon/rectum) pt2 395706002 pt2: Tumour invades muscularis propria (colon/rectum) Maximum degree of local invasion into or through the bowel wall 17.02.28534 84883-8 pt3 pt4a 395707006 pt3: Tumour invades through the muscularis propria into the subserosa or into non-peritonealized pericolic or perirectal tissues (colon/rectum) 384612007 pt4a: Tumour directly invades other organs or structures (colon/rectum) pt4b 384613002 pt4b: Tumour penetrates visceral peritoneum (colon/rectum) Involved Distal Proximal 369691009 Large intestine, distal surgical margin, involved by tumor 372446006 Anal, distal surgical margin involved by tumor 369690005 Large intestine, proximal surgical margin, involved by tumor 372444009 Anal, proximal surgical margin involved by tumor 369708000 Large intestine, distal surgical margin not involved by tumor Distal 372445005 Anal, distal surgical margin not involved by tumor Involvement of the proximal or distal resection ('cut end') margins 17.02.28348 84884-6 Not involved Proximal 369707005 Large intestine, proximal surgical margin not involved by tumor 372443003 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 81183-6 if not involved Clearance 17.02.28396 Distance of tumor from closest proximal margin 81182-8 Blue italic text = Coentary / Special coents to assist with reporting Clearance 10 LN-RCPA-00104 17.02.30019 Involved 248448006 Involved Not involved 813801000168109 Not involved Status of the nonperitonealised circumferential margin 17.02.28354 84885-3 if not involved Microscopic clearance 17.02.28400 81184-4 (3rd Ed 52101004 Site 17.02.28403 39111-0 Site [1..n] - record text (site) 17.02.28338 21892-5 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 17.02.28406 21893-3 Number of positive: 17.02.27973 Total number of nodes 17.02.28437 21894-1 Isolated extra-mural tumour deposits 17.02.28392 84889-5 52101004 Apical node involvement 17.02.28407 84887-9 52101004 Not applicable 385432009 Not applicable 814141000168101 Intramural venous invasion not identified Intramural vein invasion 17.02.28412 84888-7 369733002 Venous (large vessel) intramural invasion by tumour present (venous) 395718006 Lymphatic (small vessel) intramural invasion by tumour present (small vessel) 814501000168109 Extramural venous invasion not identified Venous and small vessel invasion 17.02.28411 33761-8 Extramural vein invasion 17.02.28415 84889-5 369734008 Venous (large vessel) extramural invasion by tumour present (venous) 395719003 Lymphatic (small vessel) extramural (small vessel) invasion by tumour present 814151000168104 Lymphatic (small vessel) invasion by tumour not identified Small vessel invasion 17.02.28418 33739-4, extensive 395717001 Lymphatic (small vessel) invasion by tumour present 814091000168108 Extensive lymphatic (small vessel) invasion by tumor present 385001000 Perineural invasion by tumour not identified Perineural invasion 17.02.28136 33741-0, extensive 369731000 Perineural invasion by tumour present 820721000168105 Extensive perineural invasion by tumour present 52101004 Histologically confirmed distant metastases 17.02.28236 84890-3 Site [1..n] 17.02.28242 21920-4 None noted 260386005 Nil Ulcerative colitis 64766004 Ulcerative colitis Ulcerative colitis with dysplasia 820651000168106 Ulcerative colitis with dysplasia Ulcerative colitis without dysplasia) 820661000168108 Ulcerative colitis without dysplasia Crohn's disease 34000006 Crohn's disease Relevant coexistent pathological abnormalities 17.02.28244 81317-0 Crohn's disease with dysplasia Crohn's disease without dysplasia 820671000168102 Crohn's disease with dysplasia 820681000168104 Crohn's disease without dysplasia Other 8251-1 Describe 254588001 Polyp of intestine Polyps Polyp details 17.02.28486 33745-1 Describe type, number, polyposis syndrome criteria met, etc Other 17.02.30003 8251-1 Microscopic residual tumour status (completeness of resection) 17.02.28425 LN-RCPA-00082 No prior treatment 820691000168101 No prior treatment Grade 0 (complete treatment) 399056007 Complete therapeutic response No viable cancer cells Response to neoadjuvant therapy 17.02.28123 84891-1 Grade 1 (moderate response) Single cells or small groups of cancer cells 84190002 Minimal therapeutic response Grade 2 (minimal response) Residual cancer outgrown by fibrosis Grade 3 (poor response) 405786003 Poor response to treatment Minimal or no tumour kill; extensive 22635-7 Microscopic coents 17.02.28431 RCPA - SPIA Report Information Model v1.0.ap - 5/01/2017 - Mindjet
Blue italic text = Coentary / Special coents to assist with reporting (3rd Ed MLH-1 17.02.28434 50322-7 820751000168102 Normal iunohistochemical staining 820761000168100 Loss of iunohistochemical staining PMS-2 17.02.28442 50328-4 820751000168102 Normal iunohistochemical staining 820761000168100 Loss of iunohistochemical staining Mismatch repair enzymes 17.02.28433 MSH-2 17.02.28493 50323-5 820751000168102 Normal iunohistochemical staining 820761000168100 Loss of iunohistochemical staining MSH-6 17.02.28544 50324-3 820751000168102 Normal iunohistochemical staining 820761000168100 Loss of iunohistochemical staining Coents 17.02.28436 8262-8 Unstable 263922001 Unstable status 17.02.28399 43368-0 Stable 58158008 Stable 17.02.28156 Microsatellite instability (MSI) 17.02.28447 8265-1 Coents 17.02.28453 Mutated 814061000168101 Mutated phenotype 17.02.28454 58483-9 Wild type 814051000168103 Wild type phenotype BRAF (V600E mutation) 17.02.28459 8264-4 Coents 17.02.28460 Mutated 814061000168101 Mutated phenotype KRAS exons 2,3 or 4; NRAS exons 2,3 or 4 or RAS mutation 17.02.28461 21703-4 Wild type 814051000168103 Wild type phenotype RAS gene mutation testing 17.02.28466 8266-9 Coents 17.02.28465 RCPA - SPIA Report Information Model v1.0.ap - 5/01/2017 - Mindjet
Blue italic text = C oentary / Spec ial c oents to as s is t with reporting (3rd Ed ptx pt0 43189003 ptx category 39880006 pt0 category ptis pt1 84921008 ptis category 53786006 pt1 category T classification 17.02.28210 21899-0 pt2 80898003 pt2 category pt3 90402004 pt3 category pt4a 443604008 pt4a category pt4b 443736009 pt4b category pnx 54452005 pnx category pn0 21917009 pn0 category pn1 45552005 pn1 category pn1a 443716008 pn1a category N classification 17.02.28220 21900-6 pn1b 443599002 pn1b category pn1c 443743003 pn1c category pn2 15076001 pn2 category pn2a 443867001 pn2a category Tumour stage (AJCC 2010) 17.02.28204 21902-2 pn2b 443452006 pn2b category cm0 19408000 pm0 category cm1 14926007 pm1 category M classification 17.02.28552 67211-3 cm1a 443841006 pm1a category cm1b 443840007 pm1b category 0 261613009 Stage 0 I 258215001 Stage 1 17.02.28253 IIA IIB 261614003 Stage 2A 261615002 Stage 2B IIC 261637009 Stage 2C Stage group 17.02.28243 21902-2 IIIA 261638004 Stage 3A IIIB 261639007 Stage 3B IIIC 261640009 Stage 3C IVA 261642001 Stage 4A IVB 261643006 Stage 4B 67203-0 Year of publication and edition of cancer staging system 17.02.30004 R0 : Complete resection, margins histologically negative, no residual tumour left after resection (primary tumour, regional nodes) 258254000 Residual tumour stage R0 Residual tumour status 17.02.28317 84892-9 R1 : Incomplete resection, margins histologically involved, microscopic tumour remains after resection of gross 278271003 Residual tumour stage R1 disease (primary tumour, regional nodes) R2: Incomplete resection, margins macroscopically involved or gross disease remains after subtotal resection 278272005 Residual tumour stage R2 (e.g. primary tumour, regional nodes or liver metastasis) Specimen type Tumour size Diagnostic suary 17.02.28842 22637-3, include: Tumour type Tumour stage Completeness of excision New primary Indeterminate 82334004 Indeterminate New primary cancer or recurrence 17.02.28472 21983-2 OR 25173007 Recurrent tumour Regional (local) recurrence 399409002 Distant metastasis present Distant metastases 17.02.30005 84878-8, describe Overarching coent 17.02.28252 22638-1 RCPA - SPIA Report Information Model v1.0.ap - 10/01/2017 - Mindjet