Colorectal cancer.

The subject of the report. Usually, but not always, this is a patient. However diagnostic services also perform analyses on specimens collected from a variety of other sources.

The practitioner that holds legal responsibility for ordering the investigation.

The diagnostic service that is responsible for issuing the report.

Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis.

This is not necessarily the source of the atomic data items - it is the entity that takes responsibility for the clinical report.

Pre Analytic component - information collection prior to specimen receipt at laboratory.

This is just a group/section header and is not a result field.

Clinical information provided on request form.

The operating surgeon name and contact details.

Presence or absence of a perforation.

If present, record the nature of perforation.

The type of perforation.

Whether a clinical obstruction is present or absent.

Anatomical location of the tumour from a given list.

For synchronous tumours indicate each other site.

Conditional on rectum being selected. Measured in cm for RCPA requirements.

Note : Synchronous tumours should be reported separately – this serves only to identify the presence of other synchronous tumours for which separate reports will be submitted.

Quantitative measurement of distance from anal verge.

Conditional on rectum being selected. Measured in cm for RCPA requirements.

Conditional on rectum being selected Note : Measured in cm by longstanding surgical convention.

The type of operation selected from a list.

Single selection value list. If other procedure(s) is selected, record type of procedure. If anterior resection is selected, record anterior resection type.

Type of procedure.

The type of anterior resection.

Single selection value list.

An indication of pre-operative radiotherapy.

Single selection value list. If yes, record type of course.

The type of course of pre-operative radiotherapy.

Surgeons opinion on the existence of local residual cancer postsurgery.

Involvement of adjacent organs.

An indication of whether a new primary cancer or a recurrence.

Single selection value list. If regional (local) recurrence or distant metastasis describe.

? If need to make an invariant due to the conditional statement.

Description of regional (local) recurrence or distant metastases.

Pathology accession number.

Other relevant details.

Macroscopic findings.

This is just a group/section header and is not a result field.

The length of the specimen.

measurement in mm.

Query if measurements are in mm is international ie USA and query if this comment needs to be refined to AUS? Ditto for subsequent metric measurements.

The site of the tumour.

Maximum tumour diameter.

measurement in mm.

Distance of tumour to the nearer proximal or distal "cut end".

measurement in mm.

Distance of tumour to the nonperitonealised circumferential margin.

measurement in mm.

The presence or absence of tumour perforation.

Single selection value list.

Site of tumour in relation to the anterior level of the peritoneal reflection.

Single selection value list. Conditional on rectum being selected in Tumour Site.

For rectal resections the intactness of the mesorectum must be recorded.

Single selection value list. Conditional on rectum being selected in Tumour Site.

Any involvement of the peritoneum should be recorded.

Single selection value list.

If lymph nodes are received, then they should be recorded.

Conditional: If received, record the number of nodes.

The number of lymph nodes placed in each cassette should be recorded.

The RCPA require the following be recorded: "Numeric: in cassette: " Query how to record this?

The presence or absence of polyps should be recorded.

Conditional: If present, provide a polyp summary.

The polyp summary should include the numbers, diameter range and gross appearance.

A descriptive or narrative field should be provided to record any macroscopic information that is not recorded in the above standards and guidelines, and that would normally form part of the macroscopic description.

The nature and sites of all blocks must be recorded.

Microscopy of the sample.

This is just a group/section header and is not a result field.

A single selection value list from WHO Classification of Tumours.

Single selection value list from WHO Classification of Tumours. Pathology and Genetics of Tumours of the Digestive System (2010).

How to represent this result group which has heading and components cf the bindings file is a flat file??

The histological grading of the tumour must be recorded.

Single selection value list.

The maximum degree of local invasion into or through the bowel wall must be recorded.

Single selection value list.

Involvement of the proximal or distal resection margins (cut-end margins) by tumour must be recorded. If the margin is less than 10 mm, the clearance must be recorded.

Single selection value list. If involved is selected, record involved margin(s) If not involved is selected, record microscopic clearance.

Involvement of the proximal or distal resection margins (cut-end margins) by tumour must be recorded. If the margin is less than 10 mm, the clearance must be recorded.

Multi select value list (select all that apply). This is a conditional field.

If the margin is less than 10 mm, the clearance must be recorded.

Numeric: ___mm (if the margin is less than 10 mm) OR Clearance is ≥10mm.

Query how to achieve this??

The status of the nonperitonealised circumferential margin in rectal tumours must be recorded.

Single selection value list. Conditional on rectum being selected in S2.02 If not involved is selected, record microscopic clearance.

In rectal tumours, the minimum distance in millimetres between the tumour and the nonperitonealised (circumferential, radial) margin must be recorded from the histological slides.

Is conditional.

Results of lymph node histopathology must be recorded.

Single selection value list. Conditional on nodes being received in G2.02. If G2.02 has been recorded as “not received” this standard is not required. If present, record site(s) and number of lymph nodes.

If lymph node(s) received then the site(s) and numbers of lymph nodes must be recorded.

Text: Site of lymph node AND Numeric: /_ (Number of positive nodes/ Total number of nodes from this site) Site is the LN drainage relevant to the site of tumour being reported.

Query if this field needs to be broken in to a number of fields??

The presence or absence of isolated extra-mural tumour deposits is to be recorded.

Single selection value list.

Involvement of the apical lymph node should be recorded.

Single selection value list.

For all tumours, venous and small vessel invasion must be reported and its anatomic location specified as intramural or extramural.

This is just a header and is not a data field ?? How to be entered in the resource.

Intramural invasion must be reported on.

Single selection value list.

Extramural invasion must be reported on.

Single selection value list.

Small vessel invasion must be reported on.

Single selection value list.

Perineural invasion must be reported on.

Single selection value list.

The presence or absence of histologically confirmed distant metastases must be recorded.

Single selection value list. If present, record sites.

The site of histologically confirmed distant metastases must be recorded.

Is conditional.

The relevant coexistent pathological abnormalities must be recorded.

Multi select value list (select all that apply). ?? How is this indicated?? If Polyps is selected provide details If Ulcerative colitis or Crohn’s disease is selected record dysplasia If other is selected, provide details in “other abnormality”.

The polyp details (type, number, polyposis syndrome criteria met etc) is to be recorded.

Is conditional.

If Ulcerative colitis or Crohns disease is selected for relevant coexistent pathological abnormalities record dysplasia.

Single selection value list. Is conditional.

Cannot have an apostrophe in a spreadsheet eg Crohn apostrophe s.

Record any other abnormality.

The microscopic residual tumour status (completeness of resection) is to be recorded.

The response to neoadjuvant therapy should be recorded.

Other Microscopic comments should be recorded.

Ancillary test findings are to be recorded.

Immunohistochemical stains for microsatellite instability will be performed and a supplementary report issued.

This is just a group/section header and is not a result field, but some example reports this field was used as a comment field.

Mismatch repair enzymes are to be recorded.

This is just a sub-group/sub-section header and is not a result field.

MLH-1 testing.

Single selection value list.

PMS-2 testing.

Single selection value list.

MSH-2 testing.

Single selection value list.

MSH-6 testing.

Single selection value list.

Mismatch repair enzyme comments can be recorded.

Microsatellite instability (MSI) to be recorded.

Single selection value list. If unstable or stable, record laboratory performing test and report number.

This is just a group/section header and is not a result field.

Microsatellite instability (MSI) to be recorded.

Microsatellite instability (MSI) comments can be recorded.

Conditional.

Microsatellite instability (MSI) laboratory performing test and report number can be recorded.

Conditional.

BRAF (V600E mutation) testing.

Single selection value list. If mutated or wild type, record laboratory performing test and report number.

This is just a group/section header and is not a result field.

BRAF (V600E mutation) testing.

BRAF (V600E mutation) comments can be recorded.

BRAF (V600E mutation) laboratory performing test and report number can be recorded.

KRAS gene mutation (codons 12 and 13) testing.

This is just a group/section header and is not a result field.

KRAS gene mutation (codons 12 and 13) testing.

KRAS gene mutation (codons 12 and 13) comments can be recorded.

KRAS gene mutation (codons 12 and 13) laboratory performing test and report number can be recorded.

Synthesis and Overview are to be recorded.

This is just a group/section header and is not a result field.

Tumour stage is to be recorded.

This is just a sub-group/sub-section header and is not a result field.

Tumour stage T is to be recorded.

Single selection value list.

Tumour stage N is to be recorded.

Single selection value list.

Tumour stage M is to be recorded.

Single selection value list.

Tumour stage grouping is to be recorded.

Single selection value list.

Check the formatting of the result group.

Year and/or edition of staging system is to be recorded.

Numeric: year AND/OR Text: Edition eg 1st, 2nd etc.

The residual tumour status must be recorded according to the AJCC Cancer Staging Manual (7th Edition).

Diagnostic summary is to be recorded.

Include: a. specimen type b. tumour site c. tumour type d. tumour stage e. completeness of excision.

New primary cancer or recurrence is to be recorded.

Single selection value list. If regional (local) recurrence or distant metastasis describe.

Description of regional (local) recurrence or distant metastases.

Conditional.

Synthesis and overview overarching comment.

Conditional.