1
RADIOTHERAPY FORM
PROCARE – prospective registration
PATHOLOGY REPORT CHECKLIST AFTER SURGICAL RESECTION (excl. local excision: cf.
specific form) REQ
Patient’s name: ……………………………………………………….
Given name: ………………………………………………………….
Registration number (provided by the data center):
…………………………………………………
Hospital/Laboratory: …………………………………………………
Date of birth: ………………………………………………………….
Pre-operative treatment (induction): …………………………………
RECTAL CANCER: Distance from anal verge … ………………cm
cTNM staging:………………………………….
ycTNM staging: ………………………………………………………



TYPE OF SURGICAL INTERVENTION


Anterior resection rectum
Restorative rectum resection (TME)
MACROSCOPIC EXAMINATION


Abdomino-perineal rectum excision (TME)
Local (transanal) excision – use specific checklist
…………………………………………………..
Depth of invasion
External surface TME
 smooth, regular
 mildly irregular
 severely irregular
fresh
fixed



Tx: primary tumor cannot be assessed
T0: no evidence of primary tumor
Tis: intra-mucosal or intra-epithelial (not beyond muscularis
mucosae)
T1: limited to submucosa
T2: limited to muscularis propria
T3: subserosal invasion (invasion beyond muscularis propria)
T4: invasion of serosa or adjacent organ(s)
Rectal tumor location:
 ventral
 ……………….
 lateral
 above peritoneal reflection
 dorsal
 below peritoneal reflection
 multifocal: if second location, please use separate sheet




Length of resected specimen: ……………………………………… cm
Distance tumor – resection margin:
proximal: …………………………………………..cm
distal: ………………………………………………cm
Surgical resection:
Rectal tumor appearance:
 exophytic  ulcerating

infiltrating

Longitudinal margins:
Proximal:
 free
 invaded
Distal:
 free
 invaded
Circumferential resection margin: ……….mm remote from tumor
flat
Extension:
Tumor
perforation
Associated
lesions
Polyp(s)
Synchronic cancer(s)
Ulcerative colitis
Crohn’s disease
Familial polyposis
Additional samples:
yes

no

yes







no





Number of lymph nodes examined:……………………………………
Number of invaded lymph nodes: …………………………………….
Number of extramural deposits < 3 mm ………………………………
Number of extramural deposits > 3 mm: …………………………….
Nx
N0
N1
N2
Extramural vascular invasion:
 yes
Metastasis (liver, peritoneum, …)
 yes
 no
frozen
other fixation ………….
HISTOLOGICAL EXAMINATION


Adenocarcinoma
 well
 moderate
 poorly differentiated



Regional lymph nodes cannot be assessed.
No regional lymph node metastasis.
Metastasis in 1 to 3 regional lymph nodes
Metastasis in 4 or more regional lymph nodes

no

impossible to determine
Rectal cancer regression grade (Dworak):
undifferentiated
low grade
high grade



grade 0 (no regression)
grade 1 (25% fibrosis)
grade 2 (26-50% fibrosis)



T0
N0
M1


grade 3 (>50% fibrosis)
grade 4 (total regression)

T2
Other: ……………………………………………………………
RECTAL CANCER

pTNM

ypTNM



Tx
Nx
Mx


Tis
N1


T1
N2

T3

T4
Other classification : ………………………………………………………………………………………………………………………………………….
Signature:
Date:
2
PATHOLOGY FORM
PROCARE – prospective registration
PATHOLOGY REPORT CHECKLIST AFTER LOCAL EXCISION REQ
Patient’s name: ……………………………………………………….
Registration number: …………………………………………………
Given name: ………………………………………………………….
Hospital/Laboratory: …………………………………………………
Date of birth: ………………………………………………………….
Pre-operative treatment (induction): …………………………………
RECTAL CANCER:
Distance from anal verge ………… cm
cTNM staging: ………………………..
ycTNM staging: …………………………
TYPE OF INTERVENTION

LOCAL (TRANSANAL) EXCISION
MACROSCOPIC EXAMINATION

HISTOLOGIC EXAMINATION

fresh

fixed
Adenocarcinoma
Rectal tumour location:

ventral

dorsal

lateral

……..

above peritoneal reflection

below peritoneal reflection

Multifocal: if second location, please use separate sheet

proximal: ……………………………………………………..cm
distal: …………………………………………………………cm

deep: ………………………………………………………….cm

low grade
poorly differentiated

high grade
-
m1
-
m2
-
m3
-
sm1
-
sm2
-
sm3

T2: limited to muscularis propria

T3
Surgical resection :
Rectal tumour location

moderate

T1: limited to submucosa
lateral: ………………………………………………………...cm
Tumour perforation:

(not beyond muscularis mucosae)
Distance tumor – resection margin:
ulcerating 
undifferentiated
Tis: intra-mucosal or intra-epithelial
Dimensions of resected specimen: ……………………………… ………cm


Depth of invasion

exophytic
well
Other: …………………………………………………………
Number of fragments ………………………………………………………..


infiltrating 
flat

yes
Longitudinal margins:
No
Proximal:

free

invaded..……..mm
Distal:

free

invaded……....mm
Lateral:

free

invaded………mm
Deep:

free

invaded………mm
Extension:
Additional samples:

frozen

other fixation
RECTAL CANCER


pTNM

lymphatic invasion

number of lymph nodes examined

number of invaded lymph nodes

T0

Nx
YpTNM
 Tis
 -m1
 -m2
 -m3
 N+
 T1
 -sm1
 -sm2
 -sm3

Other classification: ………………………………………………………………
Signature :
Date :
3
PATHOLOGY FORM
PROCARE – prospective registration
T2

T3
4
FOLLOW UP FORM
PROCARE – prospective registration