Registration form
NOPHO - Solid Tumour Registry
Kreftregisteret, Montebello, N-0310 Oslo
Send to national co-ordinator:
KSSB/Finn Wesenberg
Barneklinikken
Rikshospitalet, 0027 Oslo
NOPHO No.
National no.
To be submitted within 2 months after diagnosis, instructions other side.
NB: Separate forms for CNS-tumours
First name
Family name
Date of birth (ddmmyyyy)
Personal identity no.
  
Hospital:
Department:
Country:
 Boy
 Girl
Ethnicity (Nationality): (Encircle)
Biological mother : Scandinavian, other Caucasian - Lappish - Eskimo- Asian - African- Other ………
Biological father : Scandinavian, other Caucasian - Lappish - Eskimo- Asian - African- Other ……….
Disposing / etiological factors like family syndromes (as v. Recklinghausen), earlier irradiation, previous
cancer, immune deficiency a.o.:
Specify ………………………………………………………………………………………….
  
Date of diagnosis :
Microscopic diagnosis by:
 fine-needle aspiration
 thru-cut
 surgical specimen
  
Start of treatment :
Pathology laboratory/No:
Send copies of pathology / forms)
Diagnosis:
Primary tumour´s localisation:
organ of origin________________________
 left
 right
 midline
 bilateral
 unknown
Metastases:  yes  no
if yes, site of metastases:
 liver
 bone
 skin/subcutis
 lung
 lymph nodes local
 lymph nodes distant
 CNS
 bone marrow
 other, specify:…………………………….
Stage
 limited to the organ in question
 solitary
 multifocal
Largest tumour diameter: _______ , __ cm
If no tissue specimen, clinical diagnosis based
on:
 Ultrasound
 CT
 MRI
 Tumour markers, specify:
………………………………
 other, specify:
………………………………..
Staging system
……………………………………………………………………
……………………………………………………….
Planned first line treatment
Intention:  Cure  Palliation First line:  surgery  Chemotherapy  irradiation
Protocol (name/year)
……………………………………………………………………………………
Enrolled  yes  no
Filled in by
…………………………………………….
Name capital letters
Date
Signature
INSTRUCTIONS TO FILL IN
REGISTRATION FORM
Solid tumours outside CNS
To be registered: All tumours outside CNS, included lymphomas and histiocytic diseases. CNS
registration separate forms.
All dates are registered as:
  
d d
m m
y y y y
National co-ordinator: To be filled in by national co-ordinator in each Nordic country
NOPHO no. and National no.: Number to be filled in by national co-ordinator
Disposing/etiological factors. Specify if marked
Time of diagnosis: Date of first imaging or operation for disease which later on turned out to be a
malignant
Start of treatment: Date of surgery/chemotherapy/radiation whichever came first
Microscopic diagnosis by : mark those methods used
Diagnosis: The pathologic diagnosis (or clinical if pathology is missing)
Primary tumour’s localisation: Primary organ in question. If evaluation is not possible, mark
unknown and add abdominal or thoracic if possible
Metastases: Mark for all organs in question (not necessarily verified with biopsy)
First line: Mark for the treatment modalities planned to be used (surgery, chemotherapy and/or
irradiation)
Protocol: Give name of protocol and year activated
Enrolled: Mark “yes” if the patient is included in study of the protocol and report forms are sent to
study centre, otherwise mark “no”