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Purpose

Record Pathology information when required by the protocol.

Pathology eCRF

Field Name

Description / Instructions

Format

Surgical Pathology#

Entere the pathology Number

20 character

Surgery Date

Enter the date of the surgical procedure.

DD-MMM-YYYY

Pathology Resoults Date

Entere the pathology results date

DD-MMM-YYYY

Specify Other Procedure

 

100 characters

Body Site of Collection

 

Use Pick List

Pathology eCRF - GROSS DESCRIPTION

Field Name

Description / Instructions

Format

Pathology Sample Type

Slect the Pathology Sample Type

Use Picl List

Differentiation

 

Use Picl List

Condition of Margin

 

Use Picl List

Number of Lymph Nodes Sampled

 

Use Pick List

Number of Positive Lumph Nodes

Enter number of positive nodes

Nubmer (3)

Findings

Enter findings

24 characters

Greatest Dimension of Specimen (cm)

 

Number (6,2)

Second Greatest Dimension of Specimen (cm)

 

Number (6,2)

Stage of Disease

Enter Statge of Disease

Use Pick List

Disease T Stage

Select the stage of disease

Use Pick List

Disease N Stage

Select the stage of disease

Use Pick List

Disease M Stage

Select the stage of disease

Use Pick List

Histologic Grade

Enter the grade of histology

10 characters

Pathology eCRF - HISTOLOGY

Field Name

Description / Instructions

Format

Peritoneal Lavage Result

 

Use Pick List

Lymphatic Invasion Present

 

Use Pick List

Vascular Invasion Present

 

Use Pick List

Microcalcification Present

 

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Notable Benign Changes

 

Use Pick List

If Yes, Description (Specify )

 

200 characters

Pathology eCRF - MICROSCOPIC DESCRIPTION

Field Name

Description / Instructions

Format

Is this patient evalauable for immunostaining (IHC)

Yes
No

Use Pick List

Tumor Marker

 

Use Pick List

Analyzed

Yes
No

Use Pick List

Assay Date

 

DD-MMM-YYYY

Marker Test Method

 

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Intensity Score

 

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Cell Staining %

 

Number(3)

Mutation Detected

INDETERMINATE
NO
YES

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Result

NEGATIVE
POSSITIVE
UNKNOWN

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Biomarker Comments

Enter the comments

200 characters

Path Report Description

Enter desctioption of pathology report

200 characters