Prostate 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.

Surgical Procedure.

Nature of the specimen.

Clinical history (including Gleason grade and score of previous specimens).

Previous therapy.

Pre-biopsy serum Prostate Specific Antigen (PSA).

Units in ng/|mL.

Relevant clinical information for clinicopathological staging.

Pathology accession number.

Principal clinician.

Comments.

Macroscopic findings.

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

Specimen weight (ie Prostate without seminal vesicles).

measurement in g.

Specimen dimensions (prostate).

measured: x x mm.

Seminal Vesicles.

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

Conditional: If received, record the number of nodes.

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

Conditional: If received, record the number of nodes.

Site(s) and numbers of lymph nodes.

Note that the site and number of LNs for that site may need to be repeated for each site received.

Block identification key.

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.

Microscopy of the sample.

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

Tumour type.

Other tumour type.

Acinar variant.

Tumour location.

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

Largest nodule located by quadrant.

Single selection value list.

Largest nodule located by quadrant.

Single selection value list.

Other nodules >10mm in diameter.

Single selection value list.

If present, record the locations in quadrant and plane.

Other nodules - locations by quadrant.

Multi selection value list.

Other nodules - locations by plane.

Multi selection value list.

Intraglandular extent.

Numeric: __%.

Maximum size of dominant nodule.

Numeric: __mm.

Histological grade.

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

Primary Gleason grade.

Numeric: ___ (1-5).

Secondary Gleason grade.

Numeric: ___ (1-5).

Tertiary Gleason grade.

Numeric: ___ (3-5) or Not applicable.

Gleason score.

Extraprostatic extension.

Single selection value list.

If present, record S3.04 extent. If present, consider recording G3.04.

Extraprostatic extension - extent.

Single selection value list.

If present, record S3.04 extent. If present, consider recording G3.04.

Extraprostatic extension - locations of EPE.

Single selection value list.

If other, specify the other location.

Extraprostatic extension - other location.

Margin status.

Single selection value list:.

Involved margin location.

Multi select value list (select all that apply):.

Margin status - other location.

Involved margin extent.

Numeric: ___mm Notes: If more than 1 positive margin, record the cummulative length.

Conditional on margin involvement.

Gleason score at margin.

Numeric: Notes: If more than 1 positive margin, record the highest score.

Conditional on margin involvement.

Type of margin positivity.

Multi select value list (select all that apply):.

Conditional on margin involvement.

Seminal vesicles.

Single selection value list:.

If involved, record side.

Seminal vesicles - side.

Single selection value list:.

Bladder neck.

Single selection value list:.

Lymph node status.

This is just a group/section header and is not a result field This is conditional on receipt of LNs in S2.03.

Number of lymph nodes examined.

Numeric: __.

Number of positive lymph nodes.

Numeric: __.

If >0 consider recording G3.09 and G3.10.

The laterality of any lymph node involvement should be recorded.

Consider recording the site(s) of involved nodes.

Site(s) of involved nodes.

The maximum dimension of the largest lymph node deposit may be recorded.

Numeric: __.

Lymphovascular invasion should be recorded.

Additional microscopic comment.

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.

Primary Tumour stage T is to be recorded.

Single selection value list.

Notes: 1. Invasion into the prostate apex or into (but not beyond) the prostate capsule is not classified as T3, but as T2. * There is no pathologic T1 classification for radical prostatectomy specimens Positive surgical margin should be indicated by an R1 descriptor (residual microscopic disease).

Regional lymph nodes (N) is to be recorded.

Single selection value list.

Distant metastasis (M) is to be recorded.

Single selection value list.

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

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

Diagnostic summary is to be recorded.

Include: a. specimen type b. tumour site c. Gleason score d. tumour stage e. whether or not the specimen margins are involved.

Synthesis and overview overarching comment.

Conditional.