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The Global Clinicopathological Database
Refer to your Results sheets for the information required.
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* Indicates required question
Patient ID
*
DO NOT WRITE YOUR NAME OR HOSPITAL NUMBER HERE, Please write the ID given to you most recently by your doctor or nurse
Your answer
Specimen Weight (g)
Your answer
Specimen size (1)
Largest size in mm
Your answer
Specimen size (2)
2nd number for the size
Your answer
Specimen size (3)
3rd number for the size
Your answer
Skin Ellipse
Yes
No
Clear selection
Tumour Size (mm)
The largest tumour size
Your answer
Multiple lesions present?
No
Yes*
Clear selection
If Yes, total number of lesions
Your answer
Histological Type- simple
Select one from the first three, and one from the last two. (eg. IDC and DCIS present). If none of the first three is applicable, move on to the next question
Invasive Ductal Carcinoma (IDC)
Infiltrating Lobular Cancer (ILC)
Mixed
DCIS present *
DCIS not present
Histological Type- special
Choose
No special type
Cribiform
Papillary
Medullary
Mucinous/colloid
Tubular
Option 7
DCIS
If present choose the grade
No DCIS present
Intermediate
Low
High
Clear selection
Lymphovascular invasion?
Yes
No
Clear selection
Tumour Grade
Not Known
I
II
III
Number of Nodes examined
Axillary and Sentinel
Your answer
Number of Nodes involved
Axillary and Sentinel
Your answer
Sentinel Node
Positive
Negative
Not done
Clear selection
Extra-nodal extension?
Yes
No
Clear selection
Margins
Free
DCIS only
Invasive +/- DCIS
Clear selection
Closest margin (DCIS) (mm)
Your answer
Closest margin (invasion) (mm)
Your answer
ER Status?
ER- Estrogen Receptor
Positive
Negative
Not Done
Clear selection
ALLRED score
for ER
Your answer
PgR status
PgR- Progesterone receptor
Positive
Negative
Not Done
Clear selection
ALLRED score
for PgR
Your answer
HER2 status
HER2- Human Epidermal growth factor Receptor 2
Positive
Negative
Not done
Clear selection
Value
for HER2
Your answer
FISH score
for HER2
Your answer
Comments
Pleaes tell us your comments about this form- and how it could be made easier to fill out
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