Appendix - Clinical Annotations

This appendix outlines all the clinical annotations found under the participant hook entity.

This appendix includes the following topics.

Data Entry for Clinical Information Annotation

This section outlines the following annotations found under the participant hook entity:

Lab Annotation

This annotation helps you to capture information on the clinical and laboratory tests that the participant has undergone or is undergoing.

The following table lists the attributes of the lab annotation.

Attribute and Sub-Form Name

Action

Lab Test Name

Select the appropriate laboratory test name from the drop-down list.

Other Lab Test Name

Enter the lab test name if same is not available in the Lab Test Name drop-down list. This field can be left blank.

Test date

Enter the date laboratory test was conducted. To do this, use the calendar.

Result

Enter the result of the test conducted. This data field can store alphanumeric values, which means you can add numeric values and values like positive and negative.

Result Units

Enter the measurement units for quantitative result. You can enter the units as abbreviations, for example: gm, ml; or enter the unit name, for example: gram, milliliter.

Known Issue with LabAnnotation.result Data Type

You cannot query on a result attribute in a LabAnnotation class using enumerated conditions. The result attribute in a LabAnnotation class has a data type ofString in the database. While querying, the conditions displayed for the attribute result in the entity LabAnnotation which is non-numeric. For many LabAnnotation Tests, the result values are numeric. If the data type in the database is String for result, you cannot query the numeric values using numeric operators like <, >, <=, >=, but you can query using the non-numeric operators.

Family History Annotation

This annotation captures the data related to the family medical history of the participant. For each family member, you can capture details of one or more clinical diagnosis.

The following table lists the at tributes for the Family History Annotation.

Attribute and Sub-Form Name

Action

Relation

Select the appropriate relation name from the drop-down list.

Other Lab Test Name

Enter the relation name if the same is not available in the previous attribute's (Relation) drop-down list. Data entry in this field is optional.

General Health Diagnosis

To enter information about the General Health Diagnosis, click the Add More button.

  • Clinical Diagnosis

Select the appropriate Clinical Diagnosis from the drop-down list.

  • Other Clinical Diagnosis

Enter the clinical diagnosis value if the same is not available in the previous attribute's (Clinical Diagnosis) drop-down list. Data entry in this field is optional.

  • Age at Diagnosis

Enter the Age at Diagnosis. This field accepts integer (whole number) values only. If you enter a decimal value, the value is rounded off.

To delete a General Health Diagnosis record, select the check box next to that record and click Delete.

 

Treatment Annotation

This annotation tracks the general treatments that a participant has undergone or is undergoing.

The following table lists the attributes of the Treatment Annotation.

Attribute and Sub-Form Name

Action

Agent

Select the appropriate Agent name from the drop-down list.

Other Agent

Enter the agent name if it is not available in the previous attribute's (Agent) drop-down list. Data entry in this field is optional.

Dose

Enter the amount or dose of radiation administered to the patient. This field accepts numerical value with decimal.

Dose Unit

Enter the measurement unit for the dose of radiation.

Duration

To enter information about the Duration of the treatment, click the Add More button.

  • Start Date

Enter the date treatment began using the calendar.

  • End Date

Enter the date treatment ended using the calendar.

  • Duration In Days

Enter the number of days the treatment lasted. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

 

 

To delete a row that contains data about the duration of treatment, select the check box next to the row and click Delete.

 

Rad RX Annotation

This annotation allows you to enter the details about the radiation therapy that the participant is undergoing or has undergone.

The following table lists the attributes of the Rad RX Annotation.

Attribute and Sub-Form Name

Action

Agent

Select the appropriate radiation therapy agent name from the drop-down list.

Other Agent

Enter the radiation therapy agent name if it is not available in the previous attribute's (Agent) drop-down list. Data entry in this field is optional.

Dose

Enter the amount or dose of radiation administered to the patient. This field accepts a numerical value with decimal.

Dose Unit

Enter the measurement unit for the dose of radiation.

Duration

To enter information about the Duration of the treatment, click the Add More button.

  • Start Date

Enter the date treatment began using the calendar.

  • End Date

Enter the date treatment ended using the calendar.

  • Duration In Days

Enter the number of days the treatment lasted. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

Chemo RX Annotation

This annotation allows you to enter details about the chemotherapy that the participant is undergoing or has undergone.

The following table lists the attributes of the Chemo RX Annotation.

Attribute and Sub-Form Name

Action

Agent

Select the appropriate chemotherapy agent name from the drop-down list.

Other Agent

Enter the chemotherapy agent name if it is not available in the previous attribute's (Agent) drop-down list. This field can be left blank.

Dose

Enter the amount or dose of chemical agent administered to the patient. This field accepts a numerical value with decimal.

Dose Unit

Enter the measurement unit for the dose of chemical agent.

Duration

To enter information about the Duration of the treatment, click the Add More button.

  • Start Date

Enter the date treatment began using the calendar.

  • End Date

Enter the date treatment ended using the calendar.

  • Duration In Days

Enter the number of days the treatment lasted. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

Treatment Regimen

This section outlines the following annotations found under the participant hook entity:

This annotation helps you to capture any treatment as a part of a well-defined treatment regimen. A treatment regimen may involve one or more chemotherapy or radiation therapy or a combination of both.

The following table lists the attributes of the Treatment Regimen Annotation

Attribute and Sub-Form Name

Action

Treatment Regimen

Enter the name of the treatment regimen.

Treatment Order

To enter information about the Treatment Order, click the Add More button.

  • Cycle

Enter the sequence or cycle number of the treatment regimen.

  • Chemotherapy

To enter information about the Chemotherapy, click the Details link. Then, click the Add More button to add records for the same.

  • Radiation Therapy

To enter information about the Radiation Therapy, click the Details link. Then, click the Add More button to add records for the same.

 

 

Once you add the Chemotherapy or Radiation Therapy information, enter data for each row as described above for Chemo RX Annotation and RAD RX Annotation respectively

 

 

Environmental Exposure Health Annotation

This annotation helps in capturing information about the environmental hazards or agents to which the participant is subjected to and the duration of the exposure.

The following table lists the attributes of the Environmental Exposure Health Annotation

Attribute and Sub-Form Name

Action

Agent

Select the appropriate environmental agent from the drop-down list.

Other Agent

Enter the name of environmental agent if it is not available in the previous attribute's (Agent) drop-down list. Data entry in this field is optional.

Years Agent Free

Enter the number of years the participant was Not subjected to the environmental agent. This field accepts numerical value with decimal.

Duration

To enter information about the Duration, click the Add More button.

  • Start Date

Enter the date the environmental exposure started using the calendar.

  • End Date

Enter the date the environmental exposure ended using the calendar.

  • Duration In Days

Enter the number of days the environmental exposure lasted. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

Alcohol Health Annotation

This annotation captures the data about the alcohol consumption history of the participant.

The following table lists the attributes Alcohol Health Annotation.

Attribute/Sub-Form Name

Action

Agent

Select the agent as Ethanol from the drop-down list.

Other Agent

Enter the name of agent if you need to specify a particular alcoholic beverage. Data entry in this field is optional.

Years Agent Free

Enter the number of years participant did Not consume Alcohol. This field accepts numerical value with decimal.

Duration

To enter information about the Duration, click the Add More button.

  • Start Date

Enter the date when alcohol consumption started using the calendar.

  • End Date

Enter the date when alcohol consumption ended using the calendar.

  • Duration In Days

Enter the number of days the participant consumed alcohol. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

Drinks Per Week

Enter the number of alcoholic drinks consumed in a week. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

Smoking Health Annotation

This annotation captures information about the smoking history of the participant.

The following table lists the attributes Smoking Health Annotation.

Attribute and Sub-Form Name

Action

Agent

Select the agent as Tobacco Smoking And Tobacco Smoke or Tobacco from the drop-down list.

Other Agent

Enter the name of agent if need to specify a particular value. Data entry in this field is optional.

Years Agent Free

Enter the number of years participant did Not smoke or consume tobacco. This field accepts numerical value with decimal.

Duration

To enter information about the Duration, click the Add More button.

  • Start Date

Enter the date when smoking started using the calendar.

  • End Date

Enter the date when smoking ended using the calendar.

  • Duration In Days

Enter the number of days the participant smoked. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

Packs Per Day

Enter the number of packs of cigarettes consumed in a day. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

Health Examination Annotation

This annotation covers the participant's health by providing information on various procedures for making a medical diagnosis.

The following table lists the attributes Health Examination Annotation.

Attribute and Sub-Form Name

Action

Name of Procedure

Select the procedure from the drop-down list.

Other Procedure

Enter the name of procedure if it is not available in the previous attribute's (Name of Procedure) drop-down list. Data entry in this field is optional.

Date of Examination

Enter the date the procedure was carried out using the calendar.

New Diagnosis Health Annotation

This annotation helps you to capture information about any new disease's diagnosed in a participant.

The following table lists the attributes New Diagnosis Health Annotation.

Attribute and Sub-Form Name

Action

Name of Procedure

Select the procedure from the drop-down list.

Other Procedure

Enter the name of procedure if it is not available in the previous attribute's (Name of Procedure) drop-down list. Data entry in this field is optional.

Date of Examination

Enter the date the procedure was carried out using the calendar.

No Evident Disease Health Annotation

This annotation captures information about the procedures that confirm that the participant has no evident disease.

The following table lists the attributes No Evident Disease Health Annotation.

Attribute and Sub-Form Name

Action

Name of Procedure

Select the procedure from the drop-down list.

Other Procedure

Enter the name of procedure if it is not available in the previous attribute's (Name of Procedure) drop-down list. Data entry in this field is optional.

Date of Examination

Enter the date on which the procedure was carried out using the calendar.

Recurrence Health Examination Annotation

This annotation captures information about the procedures and diagnoses of the recurrence of a disease diagnosed in the participant earlier.

The following table lists the attributes Recurrence Health Examination Annotation.

Attribute and Sub-Form Name

Action

Name of Procedure

Select the procedure from the drop-down list.

Other Procedure

Enter the name of procedure if it is not available in the previous attribute's (Name of Procedure) drop-down list. Data entry in this field is optional.

Date of Examination

Enter the date the procedure was carried out using the calendar.

Clinical Diagnosis

Select the appropriate Clinical Diagnosis from the drop-down list.

Other Clinical Diagnosis

Enter the clinical diagnosis value if it is not available in the previous attribute's (Clinical Diagnosis) drop-down list. Data entry in this field is optional.

Local Recurrence Health Examination Annotation

This annotation captures information about the procedures used to diagnose recurrence of a disease diagnosed in the participant within the local anatomic site (same site where the disease was diagnosed earlier) in the body.

The following table lists the attributes Local Recurrence Health Examination Annotation.

Attribute and Sub-Form Name

Action

Name of Procedure

Select the procedure from the drop-down list.

Other Procedure

Enter the name of procedure if it is not available in the previous attribute's (Name of Procedure) drop-down list. Data entry in this field is optional.

Date of Examination

Enter the date the procedure was carried out using the calendar.

Clinical Diagnosis

Select the appropriate Clinical Diagnosis from the drop-down list.

Other Clinical Diagnosis

Enter the clinical diagnosis value if it is not available in the previous attribute's (Clinical Diagnosis) drop-down list. Data entry in this field is optional.

Distant Recurrence Health Examination Annotation

This annotation captures information about the procedures used to diagnose recurrence of a disease diagnosed in the participant at a distant anatomic site (site other than where the disease was diagnosed earlier) in the body.

The following table lists the attributes Distant Recurrence Health Examination Annotation.

Attribute and Sub-Form Name

Action

Name of Procedure

Select the procedure from the drop-down list.

Other Procedure

Enter the name of procedure if it is not available in the previous attribute's (Name of Procedure) drop-down list. Data entry in this field is optional.

Date of Examination

Enter the date the procedure was carried out using the calendar.

Clinical Diagnosis

Select the appropriate Clinical Diagnosis from the drop-down list.

Other Clinical Diagnosis

Enter the clinical diagnosis value if it is not available in the previous attribute's (Clinical Diagnosis) drop-down list. Data entry in this field is optional.

Tissue Site

Select the Tissue Site where the disease spread from the drop-down list.

Other Tissue Site

Enter the name of tissue site if it is not available in the previous attribute's (Tissue Site) drop-down list. Data entry in this field is optional.

Pathology-Specimen Collection Group Clinical Annotation

This section outlines the following annotations found under Specimen Collection Group:

Base Solid Tissue Pathology Annotation

This generic annotation captures the pathological details about a group of specimens collected from any organ in the body by a particular procedure.

The following table lists the attributes Base Solid Tissue Pathology Annotation.

Attribute and Sub-Form Name

Action

  1. Specimen Procedure

Select the appropriate Specimen Procedure from the drop-down list.

2. Other Specimen Procedure

Enter the name of Other Specimen Procedure if it is not available in the previous attribute's (Specimen Procedure) drop-down list. Data entry in this field is optional.

3. Histologic Type

To enter information about the Histologic Type, click the Add More button.

a) Type

Select the appropriate Histologic Type from the drop-down list.

b) Histologic Variant Type

To enter information about the Histologic Variant Type, click the Details link. Click the Add More button to add a row.

4. Other Histologic Type

Enter the variant or other Histologic type. Click Submit to save data entered and to navigate back to the main form.

5. Additional Finding

To enter information about the Additional Finding, click the Add More button.

6. Pathologic finding

Select the appropriate Pathologic Finding from the drop-down list.

a) Details

To enter information about the Details, click the Details Link. Click Add More to add a row.

  • Details

Enter the details about the Additional Finding. Click Submit to save the data entered and to navigate back to the main form.

7. Comments

Enter any additional information about the specimen, site of specimen, or other basic details.

8. Histologic Grade

To enter information about the Histologic Grade, click the Add More button.

a) Grading System Name

Select the appropriate grading system name from the drop-down list.

    • Other Grading System Name

Enter the name of grading system if it is not available in the previous attribute's (Grading System Name) drop-down list. Data entry in this field is optional.

b) Grade 

Enter the Grade. This field accepts alphanumeric values.

9. Invasion

a) Lymphatic Invasion

Select the radio button for the appropriate value for Lymphatic Invasion.

b) Venous Invasion

Select the radio button for the appropriate value for Venous Invasion.

  c) Perineural Invasion

Select the radio button for the appropriate value for Perineural Invasion.

d) Pathologic Staging

e) Primary Tumor Stage

To enter information about the Primary Tumor Stage, click the Enter Details Link.

f) Primary Tumor Stage

Select the appropriate Primary Tumor Stage from the drop-down list.

g) Regional Lymph Node

To enter information about the Regional Lymph Node, click the Enter Details link.     

    • Lymph Node Stage

Select the appropriate Lymph Node Stage from the drop-down list.

    • Number Examined

Enter the number of lymph nodes examined. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Involved

Enter the number of lymph nodes involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Positive Macroscopically

Enter the number of lymph nodes macroscopically found. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Positive Microscopically

Enter the number of lymph nodes microscopically found. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Matted Nodes

Select the radio button for the appropriate value for Matted Nodes.

10. Distant Metastasis

To enter information about the Distant Metastasis, click the Enter Details link.

a) Metastasis Stage

Select the appropriate Metastasis Stage from the drop-down list.

b) Metastasis Tissue Site

To enter information about the Metastasis Tissue Site, click the Enter Details link. Click Add More to add a row.

    • Tissue Site

Select the appropriate Tissue Site from the drop-down list.

    •   Other Tissue Site

Enter the name of tissue site if it is not available in the previous attribute's (Tissue Site) drop-down list. Data entry in this field is optional.

11. Tumor Tissue Site

To enter information about the Tumor Tissue Site, click the Add More button.

a) Site

Select the appropriate tissue site from the drop-down list.

b) Other Site

Enter the name of tissue site if it is not available in the previous attribute's (Site) drop-down list. Data entry in this field is optional.

c) Tissue Side

To enter information about the Tissue Side, click the Details Link. Click Add More to add a row.

    • Side

Select the appropriate Side from the drop-down list. Click Submit to save the data entered and to navigate back to the main form.

12. Tumor Size

a) Greatest Dimension

Enter the Greatest Dimension of the tumor. This field accepts numerical values with decimal.

b) Additional Dimension One

Enter the first dimension of the tumor. This field accepts numerical values with decimal.

c) Additional Dimension Two

Enter the second dimension of the tumor. This field accepts numerical values with decimal.

d) Cannot Be Determined

Select the check box if the tumor size cannot be determined. If this check box is selected, do not enter data in the preceding three fields (Greatest Dimension, Additional Dimension One, and Additional Dimension Two).

Base Hematology Tissue Pathology Annotation

This annotation captures the pathological details about a group of specimens collected from blood by a particular procedure.

The following table lists the attributes for Base Hematology Tissue Pathology Annotation.

Attribute and Sub-Form Name

Actiobn

  1. Specimen Procedure

Select the appropriate Specimen Procedure from the drop-down list.

2. Other Specimen Procedure

Enter the name of Other Specimen Procedure if it is not available in the previous attribute's (Specimen Procedure) drop-down list. Data entry in this field is optional.

3. Histologic Type

To enter information about the Histologic Type, click the Add More button.

a) Type

Select the appropriate Histologic Type from the drop-down list.

   b) Histologic Variant Type

To enter information about the Histologic Variant Type, click the Details link. Click the Add More button to add a row. 

c) Other Histologic Type

Enter the variant or Other Histologic Type. Click Submit to save data entered and to navigate back to the main form.

4. Additional Finding

To enter information about the Additional Finding, click the Add More button.

a) Pathologic finding

Select the appropriate Pathologic Finding from the drop-down list.

b) Details

To enter information about the Details, click the Details link. Click Add More to add a row.

    • Details

Enter the details about the Additional Finding. Click Submit to save the data entered and to navigate back to the main form.

5. Comments

Enter any additional information about the specimen, site of specimen, or other basic details.

6. Biopsy or Aspirate Site

Select appropriate biopsy or aspirate site from the drop-down list.

7. Other Biopsy or Aspirate Site

Enter the name of Other Biopsy Or Aspirate Site if it is not available in the previous attributes (Biopsy or Aspirate Site) drop-down list. Data entry in this field is optional.

8. Adequacy of Specimen

Select the radio button for the appropriate value for Adequacy of Specimen.

9. Cytogenetics

   a) Status

Select the radio button for the appropriate value for Cytogenetic study status.

b)  Result

Enter the result of the Cytogenetic study in the edit box.

10. Immuno Phenotyping

a) Status

Select the radio button for the appropriate value for Immuno Phenotyping analysis status.

b) Method Used

Enter the name of the method used to carry out Immuno Phenotyping analysis in the edit box.

c) Result

Enter the result of the Immuno Phenotyping analysis in the edit box.

Radical Prostatectomy Pathology Annotation

This annotation captures pathological details about a group of specimen collected from the Prostate gland by a procedure called Radical Prostatectomy.

The following table lists the attributes for the Radical Prostatectomy Pathology Annotation.

Attribute and Sub-Form Name

Action

  1. Specimen Procedure

Select the appropriate Specimen Procedure from the drop-down list.

2. Other Specimen Procedure

Data entry is not required in this field.

3. Histologic Type

To enter information about the Histologic Type, click the Add More button.

a) Type

Select the appropriate Histologic Type from the drop-down list.

b) Histologic Variant Type

To enter information about the Histologic Variant Type, click the Details link. Click the Add More button to add a row.

    • Other Histologic Type

Enter the variant or other Histologic type. Click Submit to save data entered and to navigate back to the main form.

4. Additional Finding

To enter information about the Additional Finding, click the Add More button.

a) Pathologic finding

Select the appropriate Pathologic Finding from the drop-down list.

b) Details

To enter information about the Details, click the Details link. Click Add More to add a row.

    • Details

Enter the details about the Additional Finding. Click Submit to save the data entered and to navigate back to the main form.

5. Comments

Enter additional information about the specimen, site of specimen, or other basic details.

6. Histologic Grade

To enter information about the Histologic Grade, click the Add More button.

a) Grading System Name#

Select the appropriate Grading System Name from the drop-down list.

b) Other Grading System Name#

Enter the name of grading system if it is not available in the previous attribute's (Grading System Name) drop-down list. Data entry in this field is optional.

    • Grade

Enter the Grade. This field accepts alphanumeric values.

7. Invasion

a) Lymphatic Invasion

Select the radio button for the appropriate value for Lymphatic Invasion.

b) Venous Invasion

Select the radio button for the appropriate value for Venous Invasion.

c) Perineural Invasion

Select the radio button for the appropriate value for Perineural Invasion.

8. Pathologic Staging

a) Primary Tumor Stage

To enter information about the Primary Tumor Stage, click the Enter Details Link.

    • Primary Tumor Stage

Select the appropriate Primary Tumor Stage from the drop-down list.

b) Regional Lymph Node

To enter information about the Regional Lymph Node, click the Enter Details link.

    • Lymph Node Stage

Select the appropriate Lymph Node Stage from the drop-down list.

    • Number Examined

Enter the number of lymph nodes examined. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Involved

Enter the number of lymph nodes Involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Positive Macroscopically

Enter the number of lymph nodes macroscopically found. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Positive Microscopically

Enter the number of lymph nodes microscopically found. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Matted Nodes

Select the radio button for the appropriate value for Matted Nodes.

c) Distant Metastasis

To enter information about the Distant Metastasis, click the Enter Details link.

    • Metastasis Stage

Select the appropriate Metastasis Stage from the drop-down list.

    • Metastasis Tissue Site

To enter information about the Metastasis Tissue Site, click the Enter Details link. Click the Add More button to add a row.

      • Tissue Site

Select the appropriate Tissue Site from the drop-down list.

      • Other Tissue Site

Enter the name of tissue site if it is not available in the previous attribute's (Tissue Site) drop-down list. Data entry in this field is optional.

9. Tumor Tissue Site

To enter information about the Tumor Tissue Site, click the Add More button.

a) Site

Select the appropriate Tissue Site from the drop-down list.

b) Other Site

Enter the name of tissue site if it is not available in the previous attribute's (Site) drop-down list. Data entry in this field is optional.

c) Tissue Side

To enter information about the Tissue Side, click the Details Link. Click Add More to add a row.

    • Side

Select the appropriate Side from the drop-down list. Click Submit to save the data entered and to navigate back to the main form.

10. Tumor Size

a) Greatest Dimension

Enter the Greatest Dimension of the tumor. This field accepts numerical values with decimal.

b) Additional Dimension One

Enter the first dimension of the tumor. This field accepts numerical values with decimal.

c) Additional Dimension Two

Enter the second dimension of the tumor. This field accepts numerical values with decimal.

d) Cannot Be Determined

Select the check box if the tumor size cannot be determined. If this check box is selected, do not enter data in the preceding three fields (Greatest Dimension, Additional Dimension One, and Additional Dimension Two).

11. Proportion Or Percent Of Prostatic Tissue Involved By Tumor

Enter the percentage of prostatic tissue involved by tumor. This field accepts numerical value with a decimal between the range (0.0,100.0).

12. Periprostatic Fat Invasion

Select the radio button for the appropriate value for Periprostatic Fat Invasion.

13. Seminal Vesicle Invasion

Select the radio button for the appropriate value for Seminal Vesicle Invasion.

14. Gleason Score

a) Primary Pattern Score

Select the appropriate Primary Pattern Gleason Score from the drop-down list.

b) Secondary Pattern Score

Select the appropriate Secondary Pattern Gleason Score from the drop-down list.

c) Tertiary Pattern Score

Select the appropriate Tertiary Pattern Gleason Score from the drop-down list.

15. Extraprostatic Invasion

a) Status

Select the radio button for the appropriate value for Extraprostatic Invasion Status.

b) Is Focal

Select the check box if the extraprostatic invasion Is Focal.

c) Extraprostatic Extension Tissue Site

To enter information about the Extraprostatic Extension Tissue Site, click the Enter Details link. 

    • Tissue Site

Select the appropriate Tissue Site from the drop-down list. Click Submit to save the data entered and to navigate back to the main form.

16. Radical Prostatectomy Margin

a) Margin Status

Select the appropriate Margin Status from the drop-down list.

b) Focality of Involved Margin

Select the radio button for the appropriate value for Focality Of Involved Margin.

c) Margin Location

To enter information about the Extraprostatic Extension Tissue Site, click the Enter Details link.

    • Involved Margin Location

Select the appropriate margin location from the drop-down list.

    • Other Location

Enter the name of other margin location if it is not available in the previous attribute's (Involved Margin Location) drop-down list. Data entry in this field is optional. Click Submit to save the data entered and to navigate back to the main form.

Needle Biopsy Prostate Pathology Annotation

This annotation captures pathological details about a group of specimen collected from the Prostate gland by a particular procedure called Needle Biopsy.

The following table lists the attributes for the Needle Biopsy Prostate Pathology Annotation.

Attribute and Sub-Form Name

Action

Specimen Procedure

Select the appropriate Specimen Procedure from the drop-down list.

Other Specimen Procedure

Do not enter data in this field.

Histologic Type

To enter information about the Histologic Type, click the Add More button.

  • Type

Select the appropriate Histologic Type from the drop-down list.

  • Histologic Variant Type

To enter information about the Histologic Variant Type, click the Details link. Click the Add More button to add a row.

    • Other Histologic Type

Enter the variant or Other Histologic Type. Click Submit to save data entered and to navigate back to the main form.

Additional Finding

To enter information about the Additional Finding, click the Add More button.

  • Pathologic finding

Select the appropriate Pathologic Finding from the drop-down list.

  • Details

To enter information about the Details, click the Details link. Click Add More to add a row.

    • Details

Enter the details about the Additional Finding. Click Submit to save the data entered and to navigate back to the main form.

Comments

Enter additional information about the specimen, site of specimen, or other basic details.

Histologic Grade

To enter information about the Histologic Grade, click the Add More button.

  • Grading System Name

Select the appropriate Grading System Name from the drop-down list.

  • Other Grading System Name

Enter the name of grading system if it is not available in the previous attribute's (Grading System Name) drop-down list. Data entry in this field is optional.

  • Grade

Enter the Grade. This field accepts alphanumeric values.

Invasion

  • Lymphatic Invasion

Select the radio button for the appropriate value for Lymphatic Invasion.

  • Venous Invasion

Select the radio button for the appropriate value for Venous Invasion.

  • Perineural Invasion

Select the radio button for the appropriate value for Perineural Invasion.

Pathologic Staging

  • Primary Tumor Stage

To enter information about the Primary Tumor Stage, click the Enter Details link.

    • Primary Tumor Stage

Select the appropriate Primary Tumor Stage from the drop-down list.

  • Regional Lymph Node

To enter information about the Regional Lymph Node, click the Enter Details link.

    • Lymph Node Stage

Select the appropriate Lymph Node Stage from the drop-down list.

    • Number Examined

Enter the number of lymph nodes examined. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Involved

Enter the number of lymph nodes Involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Positive Macroscopically

Enter the number of lymph nodes macroscopically involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Positive Microscopically

Enter the number of lymph nodes microscopically involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Matted Nodes

Select the radio button for the appropriate value for Matted Nodes.

  • Distant Metastasis

To enter information about the Distant Metastasis, click the Enter Details link.

    • Metastasis Stage

Select the appropriate Metastasis Stage from the drop-down list.

    • Metastasis Tissue Site

To enter information about the Metastasis Tissue Site, click the Enter Details link. Click Add More to add a row.

      • Tissue Site

Select the appropriate Tissue Site from the drop-down list.

      • Other Tissue Site

Enter the name of the tissue site if it is not available in the previous attribute's (Tissue Site) drop --down list. Data entry is optional.

Tumor Tissue Site

To enter information about the Tumor Tissue Site, click the Add More button.

  • Site

Select the appropriate tissue site from the drop-down list.

  • Other Site

Enter the name of tissue site if it is not available in the previous attribute's (Site) drop-down list. Data entry is optional.

  • Tissue Side

To enter information about the Tissue Side, click the Details link. Click Add More to add a row.

    • Side

Select the appropriate side from the drop-down list. Click Submit to save the data entered and to navigate back to the main form.

Tumor Size

  • Greatest Dimension

Enter the Greatest Dimension of the tumor. This field accepts numerical values with decimal.

  • Additional Dimension One

Enter the first dimension of the tumor. This field accepts numerical values with decimal.

  • Additional Dimension Two

Enter the second dimension of the tumor. This field accepts numerical values with decimal.

  • Cannot Be Determined

Select the check box if the tumor size cannot be determined. If this check box is selected, do not enter data in the preceding three fields (Greatest Dimension, Additional Dimension One, and Additional Dimension Two).

Proportion Or Percent Of Prostatic Tissue Involved By Tumor

Enter the percentage of prostatic tissue involved by tumor. This field accepts numerical value with decimal between the range (0.0,100.0).

Periprostatic Fat Invasion

Select the radio button for the appropriate value for Periprostatic Fat Invasion.

Seminal Vesicle Invasion

Select the radio button for the appropriate value for Seminal Vesicle Invasion.

Gleason Score

  • Primary Pattern Score

Select the appropriate Primary Pattern Gleason Score from the drop-down list.

  • Secondary Pattern Score

Select the appropriate Secondary Pattern Gleason Score from the drop-down list.

  • Tertiary Pattern Score

Select the appropriate Tertiary Pattern Gleason Score from the drop-down list.

Total Linear Carcinoma In Millimeter

Enter the length of the carcinoma in millimeters. This field accepts numerical values with decimal.

Core Length In Millimeter

Enter the length of the core in millimeters. This field accepts numerical values with decimal.

Other Quantification

Enter data about any other quantitative information about the tumor.

Number Of Positive Cores

Enter the number of cores found positive for the tumor. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

Total Number Of Cores

Enter the total number of cores. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

Retropubic Enucleation Pathology Annotation

This annotation captures pathological details about a group of specimen collected from the Prostate gland by a particular procedure called Retropubic Enucleation.

The following table lists the attributes for the Retropubic Enucleation Pathology Annotation.

Attribute and Sub-Form Name

Action

Specimen Procedure

Select the Suprapubic or Retropubic Enucleation specimen procedure from the drop-down list.

Other Specimen Procedure

Leave this field blank.

Histologic Type

To enter information about the Histologic Type, click the Add More button.

  • Type

Select the appropriate Histologic type from the drop-down list.

  • Histologic Variant Type

To enter information about the Histologic Variant Type, click the Details link. Click the Add More button to add a row.

    • Other Histologic Type

Enter the variant or Other Histologic Type. Click Submit to save the data entered and to navigate back to the main form.

Additional Finding

To enter information about the Additional Finding, click the Add More button.

  • Pathologic finding

Select the appropriate Pathologic Finding from the drop-down list.

  • Details

To enter information about the Details, click the Details link. Click Add More to add a row.

    • Details

Enter the details about the additional finding. Click Submit to save the data entered and to navigate back to the main form.

Comments

Enter any additional information about the specimen, site of specimen, or other basic details.

Histologic Grade

To enter information about the Histologic Grade, click the Add More button.

  • Grading System Name

Select the appropriate Grading System Name from the drop-down list.

  • Other Grading System Name

Enter the name of grading system if it is not available in the previous attribute's (Grading System Name) drop-down list. Data entry is optional.

  • Grade

Enter the Grade. This field accepts alphanumeric values.

Invasion

  • Lymphatic Invasion

Select the radio button for the appropriate value for Lymphatic Invasion.

  • Venous Invasion

Select the radio button for the appropriate value for Venous Invasion.

  • Perineural Invasion

Select the radio button for the appropriate value for Perineural Invasion.

Pathologic Staging

  • Primary Tumor Stage

To enter information about the Primary Tumor Stage, click the Enter Details link.

    • Primary Tumor Stage

Select the appropriate Primary Tumor Stage from the drop-down list.

  • Regional Lymph Node

To enter information about the Regional Lymph Node, click the Enter Details link.

    • Lymph Node Stage

Select the appropriate Lymph Node Stage from the drop-down list.

    • Number Examined

Enter the number of lymph nodes examined. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Involved

Enter the number of lymph nodes involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Positive Macroscopically

Enter the number of lymph nodes macroscopically involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Positive Microscopically

Enter the number of lymph nodes microscopically involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Matted Nodes

Select the radio button for the appropriate value for the Matted Nodes.

  • Distant Metastasis

To enter information about the Distant Metastasis, click the Enter Details link.

    • Metastasis Stage

Select the appropriate Metastasis Stage from the drop-down list.

    • Metastasis Tissue Site

To enter information about the Metastasis Tissue Site, click the Enter Details link. Click Add More to add a row.

      • Tissue Site

Select the appropriate Tissue Site from the drop-down list.

      • Other Tissue Site

Enter the name of tissue site if it is not available in the previous attribute's (Tissue Site) drop-down list. Data entry is optional.

Tumor Tissue Site

To enter information about the Tumor Tissue Site, click the Add More button.

  • Site

Select the appropriate tissue site from the drop-down list.

  • Other Site

Enter the name of tissue site if it is not available in the previous attribute's (Site) drop-down list. Data entry is optional

  • Tissue Side

To enter information about the Tissue Side, click the Details link. Click Add More to add a row.

  • Side

Select the appropriate side from the drop-down list. Click Submit to save the data entered and to navigate back to the main form.

Tumor Size

  • Greatest Dimension

Enter the Greatest Dimension of the tumor. This field accepts numerical values with decimal.

  • Additional Dimension One

Enter the first dimension of the tumor. This field accepts numerical values with decimal.

  • Additional Dimension Two

Enter the second dimension of the tumor. This field accepts numerical values with decimal.

  • Cannot Be Determined

Select the check box if the tumor size cannot be determined. If this check box is selected, do not enter data in the preceding three fields (Greatest Dimension, Additional Dimension One, and Additional Dimension Two).

Proportion Or Percent Of Prostatic Tissue Involved By Tumor

Enter the percentage of prostatic tissue involved by tumor. This field accepts numerical value with decimal between the range (0.0,100.0).

Periprostatic Fat Invasion

Select the radio button for the appropriate value for Periprostatic Fat Invasion.

Seminal Vesicle Invasion

Select the radio button for the appropriate value for Seminal Vesicle Invasion.

Gleason Score

  • Primary Pattern Score

Select the appropriate Primary Pattern Gleason score from the drop-down list.

  • Secondary Pattern Score

Select the appropriate Secondary Pattern Gleason Score from the drop-down list.

  • Tertiary Pattern Score

Select the appropriate Tertiary Pattern Gleason Score from the drop-down list.

Specimen Weight (g)

Enter the weight of specimen in grams. This field accepts numerical values with decimal.

Transurethral Prostatic Resection Pathology Annotation

This annotation captures pathological details about a group of specimen collected from the Prostate gland by a particular procedure called Transurethral Prostatic resection.

The following table lists the attributes for the Transurethral Prostatic Resection Pathology Annotation.

Attribute and Sub-Form Name

Action

Specimen Procedure

Select the Transurethral Prostatic Resection specimen procedure from the drop-down list.

Other Specimen Procedure

Leave this field blank.

Histologic Type

To enter information about the Histologic Type, click the Add More button.

  • Type

Select the appropriate Histologic 
Type from the drop-down list.

  • Histologic Variant Type

To enter information about the Histologic Variant Type, click the Details link. Click the Add More button to add a row.

    • Other Histologic Type

Enter the variant or Other Histologic Type. Click Submit to save the data entered and to navigate back to the main form.

Additional Finding

To enter information about the Additional Finding, click the Add More button.

  • Pathologic finding

Select the appropriate Pathologic Finding from the drop-down list.

  • Details

To enter information about the Details, click the Details link. Click Add More to add a row.

    • Details

Enter the details about the additional finding. Click Submit to save the data entered and to navigate back to the main form.

Comments

Enter any additional information about the specimen, site of specimen, or other basic details.

Histologic Grade

To enter information about the Histologic Grade, click the Add More button.

  • Grading System Name

Select the appropriate Grading System Name from the drop-down list. 

  • Other Grading System Name

Enter the name of the grading system if it is not available in the previous attribute's (Grading System Name) drop-down list. Data entry is optional.

  • Grade

Enter the Grade. This field accepts alphanumeric values.

Invasion

  • Lymphatic Invasion

Select the radio button for the appropriate value for Lymphatic Invasion.

  • Venous Invasion

Select the radio button for the appropriate value for Venous Invasion.

  • Perineural Invasion

Select the radio button for the appropriate value for Perineural Invasion.

Pathologic Staging

  • Primary Tumor Stage

To enter information about the Primary Tumor Stage, click the Enter Details link.

    • Primary Tumor Stage

Select the appropriate Primary Tumor Stage from the drop-down list.

  • Regional Lymph Node

To enter information about the Regional Lymph Node, click the Enter Details link.

    • Lymph Node Stage

Select the appropriate Lymph Node Stage from the drop-down list.

    • Number Examined

Enter the number of lymph nodes examined. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Involved

Enter the number of lymph nodes involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Positive Macroscopically

Enter the number of lymph nodes macroscopically involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Positive Microscopically

Enter the number of lymph nodes microscopically involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Matted Nodes

Select the radio button for the appropriate value for the Matted Nodes.

  • Distant Metastasis

To enter information about the Distant Metastasis, click the Enter Details link.

    • Metastasis Stage

Select the appropriate Metastasis Stage from the drop-down list.

    • Metastasis Tissue Site

To enter information about the Metastasis Tissue Site, click the Enter Details link. Click Add More to add a row.

      • Tissue Site

Select the appropriate Tissue Site from the drop-down list.

      • Other Tissue Site

Enter the name of tissue site if it is not available in the previous attribute's (Tissue Site) drop-down list. Data entry is optional.

Tumor Tissue Site

To enter information about the Tumor Tissue Site, click the Add More button.

  • Site

Select the appropriate tissue site from the drop-down list.

  • Other Site

Enter the name of tissue site if it is not available in the previous attribute's (Site) drop-down list. Data entry is optional

  • Tissue Side

To enter information about the Tissue Side, click the Details link. Click Add More to add a row.

    • Side

Select the appropriate side from the drop-down list. Click Submit to save the data entered and to navigate back to the main form.

Tumor Size

  • Greatest Dimension

Enter the Greatest Dimension of the tumor. This field accepts numerical values with decimal.

  • Additional Dimension One

Enter the first dimension of the tumor. This field accepts numerical values with decimal.

  • Additional Dimension Two

Enter the second dimension of the tumor. This field accepts numerical values with decimal.

  • Cannot Be Determined

Select the check box if the tumor size cannot be determined. If this check box is selected, do not enter data in the preceding three fields (Greatest Dimension, Additional Dimension One, and Additional Dimension Two).

Proportion Or Percent Of Prostatic Tissue Involved By Tumor

Enter the percentage of prostatic tissue involved by tumor. This field accepts numerical value with decimal between the range (0.0,100.0).

Periprostatic Fat Invasion

Select the radio button for the appropriate value for Periprostatic Fat Invasion.

Seminal Vesicle Invasion

Select the radio button for the appropriate value for Seminal Vesicle Invasion.

Gleason Score

  • Primary Pattern Score

Select the appropriate Primary Pattern Gleason Score from the drop-down list. 

  • Secondary Pattern Score

Select the appropriate Secondary Pattern Gleason Score from the drop-down list.

  • Tertiary Pattern Score

Select the appropriate Tertiary Pattern Gleason Score from the drop-down list.

Specimen Weight (g)

Enter the weight of the specimen in grams. This field accepts numerical values with decimal.

Is Tumor Incidental Histologic Finding Above5 Percent

Select the check box if the percentage of incidental histologic finding is more than 5%.

Number Of Positive Chips

Enter the Number of Positive Chips found for the tumor. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

Total Number Of Chips

Enter the Total Number Of Chips. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

Pancreas Pathology Annotation

This annotation captures the pathological details about a group of specimen collected from the Pancreas by a particular procedure.

The following table lists the attributes for the Pancreas Pathology Annotation.

Attribute and Sub-Form Name

Action

Specimen Procedure

Select the appropriate specimen procedure from the drop-down list.

Other Specimen Procedure

Leave this field blank.

Histologic Type

To enter information about the Histologic Type, click the Add More button.

  • Type

Select the appropriate Histologic 
Type from the drop-down list.

  • Histologic Variant Type

To enter information about the Histologic Variant Type, click the Details link. Click the Add More button to add a row.

    • Other Histologic Type

Enter the variant or Other Histologic Type. Click Submit to save the data entered and to navigate back to the main form.

Additional Finding

To enter information about the Additional Finding, click the Add More button.

  • Pathologic finding

Select the appropriate Pathologic Finding from the drop-down list.

  • Details

To enter information about the Details, click the Details link. Click Add More to add a row.

    • Details

Enter the details about the additional finding. Click Submit to save the data entered and to navigate back to the main form.

Comments

Enter any additional information about the specimen, site of specimen, or other basic details.

Histologic Grade

To enter information about the Histologic Grade, click the Add More button.

  • Grading System Name

Select the appropriate Grading System Name from the drop-down list. 

  • Other Grading System Name

Enter the name of the grading system if it is not available in the previous attribute's (Grading System Name) drop-down list. Data entry is optional.

  • Grade

Enter the Grade. This field accepts alphanumeric values.

Invasion

  • Lymphatic Invasion

Select the radio button for the appropriate value for Lymphatic Invasion.

  • Venous Invasion

Select the radio button for the appropriate value for Venous Invasion.

  • Perineural Invasion

Select the radio button for the appropriate value for Perineural Invasion.

Pathologic Staging

  • Primary Tumor Stage

To enter information about the Primary Tumor Stage, click the Enter Details link.

    • Primary Tumor Stage

Select the appropriate Primary Tumor Stage from the drop-down list.

  • Regional Lymph Node

To enter information about the Regional Lymph Node, click the Enter Details link.

    • Lymph Node Stage

Select the appropriate Lymph Node Stage from the drop-down list.

    • Number Examined

Enter the number of lymph nodes examined. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Involved

Enter the number of lymph nodes involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Positive  Macroscopically

Enter the number of lymph nodes macroscopically involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Positive  Microscopically

Enter the number of lymph nodes microscopically involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Matted Nodes

Select the radio button for the appropriate value for the Matted Nodes.

  • Distant Metastasis

To enter information about the Distant Metastasis, click the Enter Details link.

  • Metastasis Stage

Select the appropriate Metastasis Stage from the drop-down list.

  • Metastasis Tissue Site

To enter information about the Metastasis Tissue Site, click the Enter Details link. Click Add More to add a row.

    • Tissue Site

Select the appropriate Tissue Site from the drop-down list.

    • Other Tissue Site

Enter the name of tissue site if it is not available in the previous attribute's (Tissue Site) drop-down list. Data entry is optional.

Tumor Tissue Site

To enter information about the Tumor Tissue Site, click the Add More button.

  • Site

Select the appropriate tissue site from the drop-down list.

  • Other Site

Enter the name of tissue site if it is not available in the previous attribute's (Site) drop-down list. Data entry is optional

  • Tissue Side

To enter information about the Tissue Side, click the Details link. Click Add More to add a row.

    • Side

Select the appropriate side from the drop-down list. Click Submit to save the data entered and to navigate back to the main form.

Tumor Size

 

  • Greatest Dimension

Enter the Greatest Dimension of the tumor. This field accepts numerical values with decimal.

  • Additional Dimension One

Enter the first dimension of the tumor. This field accepts numerical values with decimal.

  • Additional Dimension Two

Enter the second dimension of the tumor. This field accepts numerical values with decimal.

  • Cannot Be Determined

Select the check box if the tumor size cannot be determined. If this check box is selected, do not enter data in the preceding three fields (Greatest Dimension, Additional Dimension One, and Additional Dimension Two).

Other Resected Organs

To enter information about the Other Resected Organ, click the Add More button.

  • Other Organs Resected

Select the appropriate resected organ name from the drop-down list.

  • Other Other Organs Resected

Enter the name of other organ resected if it is not available in the previous attribute's (Other Organs Resected) drop-down list. Data entry is optional.

Pancreas Margin

  • Margin Status

Select the appropriate pancreas margin from the drop-down list.

  • Involved Margin

To enter information about the Involved Margin, click the Enter Details link. Click Add More to add a row.

    • Margin Location

Select the appropriate location of margin involved by invasive carcinoma from the drop-down list.

    • Other Margin Location

Enter the name of the other involved margin location if it is not available in the previous attribute's (Margin Location) drop-down list. Data entry is optional.

  • Uninvolved Margin

To enter information about the Uninvolved Margin, click the Enter Details link.

    • Margin Location

Enter the location of the margin uninvolved by invasive carcinoma in the edit box.

    • Closest Distance To Tumor

Enter the distance closest to tumor. This field accepts numerical values with decimal.

    • Carcinoma In Situ Status

To enter information about the Carcinoma In Situ Status, click the Enter Details link. Click Add More to add a row. 

      • Status

Select the appropriate status for the carcinoma in situ from the drop-down list. Click Submit to save the data entered and to navigate back to main form.

Lung Biopsy Pathology Annotation

This annotation captures pathological details about a group of specimen collected from the Lung by a particular procedure Biopsy.

The following table lists the attributes for the Lung Biopsy Pathology Annotation.

Attribute and Sub-Form Name

Action

Specimen Procedure

Select the Biopsy specimen procedure from the drop-down list.

Other Specimen Procedure

Leave this field blank.

Histologic Type

To enter information about the Histologic Type, click the Add More button.

  • Type

Select the appropriate Histologic 
Type from the drop-down list.

  • Histologic Variant Type

To enter information about the Histologic Variant Type, click the Details link. Click the Add More button to add a row.

    • Other Histologic Type

Enter the variant or Other Histologic Type. Click Submit to save the data entered and to navigate back to the main form.

Additional Finding

To enter information about the Additional Finding, click the Add More button.

  • Pathologic finding

Select the appropriate Pathologic Finding from the drop-down list.

  • Details

To enter information about the Details, click the Details link. Click Add More to add a row.

    • Details

Enter the details about the additional finding. Click Submit to save the data entered and to navigate back to the main form.

Comments

Enter any additional information about the specimen, site of specimen, or other basic details.

Histologic Grade

To enter information about the Histologic Grade, click the Add More button.

  • Grading System Name

Select the appropriate Grading System Name from the drop-down list. 

  • Other Grading System Name

Enter the name of the grading system if it is not available in the previous attribute's (Grading System Name) drop-down list. Data entry is optional.

  • Grade

Enter the Grade. This field accepts alphanumeric values.

Invasion

  • Lymphatic Invasion

Select the radio button for the appropriate value for Lymphatic Invasion.

  • Venous Invasion

Select the radio button for the appropriate value for Venous Invasion.

  • Perineural Invasion

Select the radio button for the appropriate value for Perineural Invasion.

Pathologic Staging

  • Primary Tumor Stage

To enter information about the Primary Tumor Stage, click the Enter Details link.

    • Primary Tumor Stage

Select the appropriate Primary Tumor Stage from the drop-down list.

  • Regional Lymph Node

To enter information about the Regional Lymph Node, click the Enter Details link.

    • Lymph Node Stage

Select the appropriate Lymph Node Stage from the drop-down list.

    • Number Examined

Enter the number of lymph nodes examined. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Involved

Enter the number of lymph nodes involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Positive  Macroscopically

Enter the number of lymph nodes macroscopically involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Positive  Microscopically

Enter the number of lymph nodes microscopically involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Matted Nodes

Select the radio button for the appropriate value for the Matted Nodes.

  • Distant Metastasis

To enter information about the Distant Metastasis, click the Enter Details link.

    • Metastasis Stage

Select the appropriate Metastasis Stage from the drop-down list.

    • Metastasis Tissue Site

To enter information about the Metastasis Tissue Site, click the Enter Details link. Click Add More to add a row.

      • Tissue Site

Select the appropriate Tissue Site from the drop-down list.

      • Other Tissue Site

Enter the name of tissue site if it is not available in the previous attribute's (Tissue Site) drop-down list. Data entry is optional.

Tumor Tissue Site

To enter information about the Tumor Tissue Site, click the Add More button.

    • Site

Select the appropriate tissue site from the drop-down list.

  • Other Site

Enter the name of tissue site if it is not available in the previous attribute's (Site) drop-down list. Data entry is optional

  • Tissue Side

To enter information about the Tissue Side, click the Details link. Click Add More to add a row.

    • Side

Select the appropriate side from the drop-down list. Click Submit to save the data entered and to navigate back to the main form.

Tumor Size

  • Greatest Dimension

Enter the Greatest Dimension of the tumor. This field accepts numerical values with decimal.

  • Additional Dimension One

Enter the first dimension of the tumor. This field accepts numerical values with decimal.

  • Additional Dimension Two

Enter the second dimension of the tumor. This field accepts numerical values with decimal.

  • Cannot Be Determined

Select the check box if the tumor size cannot be determined. If this check box is selected, do not enter data in the preceding three fields (Greatest Dimension, Additional Dimension One, and Additional Dimension Two).

Visceral Pleural Invasion

Select the radio button for the appropriate value for Visceral Pleural Invasion.

Lung Resection Based Pathology Annotation

This annotation captures pathological details about a group of specimen collected from the Lung by a procedure called Resection.

The following table lists the attributes for the Lung Resection Based Pathology Annotation.

Attribute and Sub-Form Name

Action

Specimen Procedure

Select the Total Resection specimen procedure from the drop-down list.

Other Specimen Procedure

Leave this field blank.

Histologic Type

To enter information about the Histologic Type, click the Add More button.

  • Type

Select the appropriate Histologic 
Type from the drop-down list.

  • Histologic Variant Type

To enter information about the Histologic Variant Type, click the Details link. Click the Add More button to add a row.

    • Other Histologic Type

Enter the variant or Other Histologic Type. Click Submit to save the data entered and to navigate back to the main form.

Additional Finding

To enter information about the Additional Finding, click the Add More button.

  • Pathologic finding

Select the appropriate Pathologic Finding from the drop-down list.

  • Details

To enter information about the Details, click the Details link. Click Add More to add a row.

    • Details

Enter the details about the additional finding. Click Submit to save the data entered and to navigate back to the main form.

Comments

Enter any additional information about the specimen, site of specimen, or other basic details.

Histologic Grade

To enter information about the Histologic Grade, click the Add More button.

  • Grading System Name

Select the appropriate Grading System Name from the drop-down list. 

  • Other Grading System Name

Enter the name of the grading system if it is not available in the previous attribute's (Grading System Name) drop-down list. Data entry is optional.

  • Grade

Enter the Grade. This field accepts alphanumeric values.

Invasion

  • Lymphatic Invasion

Select the radio button for the appropriate value for Lymphatic Invasion.

  • Venous Invasion

Select the radio button for the appropriate value for Venous Invasion.

  • Perineural Invasion

Select the radio button for the appropriate value for Perineural Invasion.

Pathologic Staging

  • Primary Tumor Stage

To enter information about the Primary Tumor Stage, click the Enter Details link.

    • Primary Tumor Stage

Select the appropriate Primary Tumor Stage from the drop-down list.

  • Regional Lymph Node

To enter information about the Regional Lymph Node, click the Enter Details link.

    • Lymph Node Stage

Select the appropriate Lymph Node Stage from the drop-down list.

    • Number Examined

Enter the number of lymph nodes examined. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Involved

Enter the number of lymph nodes involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Positive  Macroscopically

Enter the number of lymph nodes macroscopically involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Positive Microscopically

Enter the number of lymph nodes microscopically involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Matted Nodes

Select the radio button for the appropriate value for the Matted Nodes.

  • Distant Metastasis

To enter information about the Distant Metastasis, click the Enter Details link.

    • Metastasis Stage

Select the appropriate Metastasis Stage from the drop-down list.

    • Metastasis Tissue Site

To enter information about the Metastasis Tissue Site, click the Enter Details link. Click Add More to add a row.

      • Tissue Site

Select the appropriate Tissue Site from the drop-down list.

      • Other Tissue Site

Enter the name of tissue site if it is not available in the previous attribute's (Tissue Site) drop-down list. Data entry is optional.

Tumor Tissue Site

To enter information about the Tumor Tissue Site, click the Add More button.

  • Site

Select the appropriate tissue site from the drop-down list.

  • Other Site

Enter the name of tissue site if it is not available in the previous attribute's (Site) drop-down list. Data entry is optional

  • Tissue Side

To enter information about the Tissue Side, click the Details link. Click Add More to add a row.

    • Side

Select the appropriate side from the drop-down list. Click Submit to save the data entered and to navigate back to the main form.

Tumor Size

  • Greatest Dimension

Enter the Greatest Dimension of the tumor. This field accepts numerical values with decimal.

  • Additional Dimension One

Enter the first dimension of the tumor. This field accepts numerical values with decimal.

  • Additional Dimension Two

Enter the second dimension of the tumor. This field accepts numerical values with decimal.

  • Cannot Be Determined

Select the check box if the tumor size cannot be determined. If this check box is selected, do not enter data in the preceding three fields (Greatest Dimension, Additional Dimension One, and Additional Dimension Two).

Direct Extension of Tumor

To enter information about the Direct Extension of Tumor, click the Add More button.

Extension of tumor

Select the appropriate tumor extension form the drop-down list.

Other Tumor Extensions

Enter the tumor extension details if it is not available in the previous attribute's (Extension of Tumor) drop-down list. Data entry is optional.

Arterial Invasion

Select the radio button for the appropriate value for Arterial Invasion.

Lung Resection Margin

To enter information about the Lung Resection Margin, click the Add More button.

  • Margin Status

Select the appropriate Lung Margin Status from the drop-down list.

  • Margin Location

Select the appropriate margin location involved by invasive carcinoma from the drop-down list.

  • Other Location

Enter the name of the other involved margin location if it is not available in the previous attribute's (Margin Location) drop-down list. Data entry is optional.

  • Uninvolved Margin

To enter information about the Uninvolved Margin, click the Details link.

    • Closest Distance To Tumor

Enter the distance closest to the tumor. This field accepts numerical values with decimal. Click Submit to save the data entered and to navigate back to the main form.

Kidney Biopsy Based Pathology Annotation

This annotation captures pathological details about a group of specimen collected from the kidney by a particular procedure Biopsy.

The following table lists the attributes for the Kidney Biopsy Based Pathology Annotation

Attribute and Sub-Form Name

Action

Specimen Procedure

Select the appropriate specimen procedure from the drop-down list.

Other Specimen Procedure

Leave this field blank.

Histologic Type

To enter information about the Histologic Type, click the Add More button.

  • Type

Select the appropriate Histologic 
Type from the drop-down list.

  • Histologic Variant Type

To enter information about the Histologic Variant Type, click the Details link. Click the Add More button to add a row.

    • Other Histologic Type

Enter the variant or Other Histologic Type. Click Submit to save the data entered and to navigate back to the main form.

Additional Finding

To enter information about the Additional Finding, click the Add More button.

  • Pathologic finding

Select the appropriate Pathologic Finding from the drop-down list.

  • Details

To enter information about the Details, click the Details link. Click Add More to add a row.

    • Details

Enter the details about the additional finding. Click Submit to save the data entered and to navigate back to the main form.

Comments

Enter any additional information about the specimen, site of specimen, or other basic details.

Histologic Grade

To enter information about the Histologic Grade, click the Add More button.

    • Grading System Name

Select the appropriate Grading System Name from the drop-down list. 

    • Other Grading System Name

Enter the name of the grading system if it is not available in the previous attribute's (Grading System Name) drop-down list. Data entry is optional.

    • Grade

Enter the Grade. This field accepts alphanumeric values.

Invasion

  • Lymphatic Invasion

Select the radio button for the appropriate value for Lymphatic Invasion.

  • Venous Invasion

Select the radio button for the appropriate value for Venous Invasion.

  • Perineural Invasion

Select the radio button for the appropriate value for Perineural Invasion.

Pathologic Staging

  • Primary Tumor Stage

To enter information about the Primary Tumor Stage, click the Enter Details link.

    • Primary Tumor Stage

Select the appropriate Primary Tumor Stage from the drop-down list.

  • Regional Lymph Node

To enter information about the Regional Lymph Node, click the Enter Details link.

    • Lymph Node Stage

Select the appropriate Lymph Node Stage from the drop-down list.

    • Number Examined

Enter the number of lymph nodes examined. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Involved

Enter the number of lymph nodes involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Positive  Macroscopically

Enter the number of lymph nodes macroscopically involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Positive Microscopically

Enter the number of lymph nodes microscopically involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Matted Nodes

Select the radio button for the appropriate value for the Matted Nodes.

  • Distant Metastasis

To enter information about the Distant Metastasis, click the Enter Details link.

    • Metastasis Stage

Select the appropriate Metastasis Stage from the drop-down list.

    • Metastasis Tissue Site

To enter information about the Metastasis Tissue Site, click the Enter Details link. Click Add More to add a row.

      • Tissue Site

Select the appropriate Tissue Site from the drop-down list.

      • Other Tissue Site

Enter the name of tissue site if it is not available in the previous attribute's (Tissue Site) drop-down list. Data entry is optional.

Tumor Tissue Site

To enter information about the Tumor Tissue Site, click the Add More button.

  • Site

Select the appropriate tissue site from the drop-down list.

  • Other Site

Enter the name of tissue site if it is not available in the previous attribute's (Site) drop-down list. Data entry is optional

  • Tissue Side

To enter information about the Tissue Side, click the Details link. Click Add More to add a row.

    • Side

Select the appropriate side from the drop-down list. Click Submit to save the data entered and to navigate back to the main form.

Tumor Size

  • Greatest Dimension

Enter the Greatest Dimension of the tumor. This field accepts numerical values with decimal.

  • Additional Dimension One

Enter the first dimension of the tumor. This field accepts numerical values with decimal.

  • Additional Dimension Two

Enter the second dimension of the tumor. This field accepts numerical values with decimal.

  • Cannot Be Determined

Select the check box if the tumor size cannot be determined. If this check box is selected, do not enter data in the preceding three fields (Greatest Dimension, Additional Dimension One, and Additional Dimension Two).

Percent Of Sarcomatoid Element

Enter the percentage of Sarcomatoid element observed. This field accepts numerical value with decimal between the range (0.0,100.0)

Kidney Nephrectomy Pathology Annotation

This annotation captures pathological details about a group of specimen collected from the kidney by a particular procedure Nephrectomy.

The following table lists the attributes for the Kidney Nephrectomy Pathology Annotation.

Attribute and Sub-Form Name

Action

Specimen Procedure

Select the appropriate specimen procedure from the drop-down list.

Other Specimen Procedure

Leave this field blank.

Histologic Type

To enter information about the Histologic Type, click the Add More button.

  • Type

Select the appropriate Histologic 
Type from the drop-down list.

  • Histologic Variant Type

To enter information about the Histologic Variant Type, click the Details link. Click the Add More button to add a row.

    • Other Histologic Type

Enter the variant or Other Histologic Type. Click Submit to save the data entered and to navigate back to the main form.

Additional Finding

To enter information about the Additional Finding, click the Add More button.

  • Pathologic finding

Select the appropriate Pathologic Finding from the drop-down list.

  • Details

To enter information about the Details, click the Details link. Click Add More to add a row.

    • Details

Enter the details about the additional finding. Click Submit to save the data entered and to navigate back to the main form.

Comments

Enter any additional information about the specimen, site of specimen, or other basic details.

Histologic Grade

To enter information about the Histologic Grade, click the Add More button.

  • Grading System Name

Select the appropriate Grading System Name from the drop-down list. 

  • Other Grading System Name

Enter the name of the grading system if it is not available in the previous attribute's (Grading System Name) drop-down list. Data entry is optional.

  • Grade

Enter the Grade. This field accepts alphanumeric values.

Invasion

  • Lymphatic Invasion

Select the radio button for the appropriate value for Lymphatic Invasion.

  • Venous Invasion

Select the radio button for the appropriate value for Venous Invasion.

  • Perineural Invasion

Select the radio button for the appropriate value for Perineural Invasion.

Pathologic Staging

  • Primary Tumor Stage

To enter information about the Primary Tumor Stage, click the Enter Details link.

    • Primary Tumor Stage

Select the appropriate Primary Tumor Stage from the drop-down list.

  • Regional Lymph Node

To enter information about the Regional Lymph Node, click the Enter Details link.

    • Lymph Node Stage

Select the appropriate Lymph Node Stage from the drop-down list.

    • Number Examined

Enter the number of lymph nodes examined. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Involved

Enter the number of lymph nodes involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Positive  Macroscopically

Enter the number of lymph nodes macroscopically involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Positive  Microscopically

Enter the number of lymph nodes microscopically involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Matted Nodes

Select the radio button for the appropriate value for the Matted Nodes.

  • Distant Metastasis

To enter information about the Distant Metastasis, click the Enter Details link.

    • Metastasis Stage

Select the appropriate Metastasis Stage from the drop-down list.

    • Metastasis Tissue Site

To enter information about the Metastasis Tissue Site, click the Enter Details link. Click Add More to add a row.

      • Tissue Site

Select the appropriate Tissue Site from the drop-down list.

      • Other Tissue Site

Enter the name of tissue site if it is not available in the previous attribute's (Tissue Site) drop-down list. Data entry is optional.

Tumor Tissue Site

To enter information about the Tumor Tissue Site, click the Add More button.

  • Site

Select the appropriate tissue site from the drop-down list.

  • Other Site

Enter the name of tissue site if it is not available in the previous attribute's (Site) drop-down list. Data entry is optional

  • Tissue Side

To enter information about the Tissue Side, click the Details link. Click Add More to add a row.

    • Side

Select the appropriate side from the drop-down list. Click Submit to save the data entered and to navigate back to the main form.

Tumor Size

  • Greatest Dimension

Enter the Greatest Dimension of the tumor. This field accepts numerical values with decimal.

  • Additional Dimension One

Enter the first dimension of the tumor. This field accepts numerical values with decimal.

  • Additional Dimension Two

Enter the second dimension of the tumor. This field accepts numerical values with decimal.

  • Cannot Be Determined

Select the check box if the tumor size cannot be determined. If this check box is selected, do not enter data in the preceding three fields (Greatest Dimension, Additional Dimension One, and Additional Dimension Two).

Percent of Sarcomatoid Element

Enter the percentage of Sarcomatoid element observed. This field accepts numerical value with decimal between the range (0.0,100.0).

Focality

Select the radio button for the appropriate value for Focality of tumor.

Macroscopic Extent of Tumor

To enter information about the Macroscopic Extent of Tumor, click the Add More button.

  • Extent of Tumor

Select the appropriate tumor extension type from the drop-down list.

Adrenal Gland Stage

Select the radio button for the appropriate value for Adrenal Gland Stage.

Kidney Nephrectomy Margin

Margin Status

Select the appropriate Margin Status from the drop-down list.

Margin Location

To enter information about the Involved Margin, click the Enter Details link. Click Add More to add a row.

  • Location

Select the appropriate location of the involved margin by invasive carcinoma from the drop-down list.

  • Other Location

Enter the name of other involved margin location if it is not available in the previous attribute's (Margin Location) drop-down list. Data entry is optional. Click Submit to save the data entered and to navigate back to the main form.

Melanoma Pathology Annotation

This annotation captures pathological details about a group of specimen collected from the skin by a particular procedure.

The following table lists the attributes for the Melanoma Pathology Annotation.

Attribute and Sub-Form Name

Action

Specimen Procedure

Select the appropriate Specimen Procedure from the drop-down list.

Other Specimen Procedure

Enter the name of Other Specimen Procedure if it is not available in the previous attribute's (Specimen Procedure) drop-down list. Data entry is optional.

Histologic Type

To enter information about the Histologic Type, click the Add More button.

  • Type

Select the appropriate Histologic 
Type from the drop-down list.

  • Histologic Variant Type

To enter information about the Histologic Variant Type, click the Details link. Click the Add More button to add a row.

    • Other Histologic Type

Enter the variant or Other Histologic Type. Click Submit to save the data entered and to navigate back to the main form.

Additional Finding

To enter information about the Additional Finding, click the Add More button.

  • Pathologic finding

Select the appropriate Pathologic Finding from the drop-down list.

  • Details

To enter information about the Details, click the Details link. Click Add More to add a row.

    • Details

Enter the details about the additional finding. Click Submit to save the data entered and to navigate back to the main form.

Comments

Enter any additional information about the specimen, site of specimen, or other basic details.

Histologic Grade

To enter information about the Histologic Grade, click the Add More button.

  • Grading System Name

Select the appropriate Grading System Name from the drop-down list.

  • Other Grading System Name

Enter the name of the grading system if it is not available in the previous attribute's (Grading System Name) drop-down list. Data entry is optional.

  • Grade

Enter the Grade. This field accepts alphanumeric values.

Invasion

  • Lymphatic Invasion

Select the radio button for the appropriate value for Lymphatic Invasion.

  • Venous Invasion

Select the radio button for the appropriate value for Venous Invasion.

  • Perineural Invasion

Select the radio button for the appropriate value for Perineural Invasion.

Pathologic Staging

  • Primary Tumor Stage

To enter information about the Primary Tumor Stage, click the Enter Details link.

    • Primary Tumor Stage

Select the appropriate Primary Tumor Stage from the drop-down list.

  • Regional Lymph Node

To enter information about the Regional Lymph Node, click the Enter Details link.

    • Lymph Node Stage

Select the appropriate Lymph Node Stage from the drop-down list.

    • Number Examined

Enter the number of lymph nodes examined. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Involved

Enter the number of lymph nodes involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Positive Macroscopically

Enter the number of lymph nodes macroscopically involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Positive  Microscopically

Enter the number of lymph nodes microscopically involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Matted Nodes

Select the radio button for the appropriate value for the Matted Nodes.

  • Distant Metastasis

To enter information about the Distant Metastasis, click the Enter Details link.

    • Metastasis Stage

Select the appropriate Metastasis Stage from the drop-down list.

    • Metastasis Tissue Site

To enter information about the Metastasis Tissue Site, click the Enter Details link. Click Add More to add a row.

      • Tissue Site

Select the appropriate Tissue Site from the drop-down list.

      • Other Tissue Site

Enter the name of tissue site if it is not available in the previous attribute's (Tissue Site) drop-down list. Data entry is optional.

Tumor Tissue Site

To enter information about the Tumor Tissue Site, click the Add More button.

  • Site

Select the appropriate tissue site from the drop-down list.

  • Other Site

Enter the name of tissue site if it is not available in the previous attribute's (Site) drop-down list. Data entry is optional

  • Tissue Side

To enter information about the Tissue Side, click the Details link. Click Add More to add a row.

    • Side

Select the appropriate side from the drop-down list. Click Submit to save the data entered and to navigate back to the main form.

Tumor Size

  • Greatest Dimension

Enter the Greatest Dimension of the tumor. This field accepts numerical values with decimal.

  • Additional Dimension One

Enter the first dimension of the tumor. This field accepts numerical values with decimal.

  • Additional Dimension Two

Enter the second dimension of the tumor. This field accepts numerical values with decimal.

  • Cannot Be Determined

Select the check box if the tumor size cannot be determined. If this check box is selected, do not enter data in the preceding three fields (Greatest Dimension, Additional Dimension One, and Additional Dimension Two).

Macroscopic Tumor

Select the radio button for the appropriate value for Macroscopic Tumor.

Pigmentation

Select the radio button for the appropriate value for Pigmentation.

Ulceration

Select the radio button for the appropriate value for Ulceration.

Depth Of Invasion Cannot Be Determined

Select the check box if the depth of invasion cannot be determined.

Depth Of Invasion(mm)

Enter the value for Depth Of Invasion, if determined. This field accepts numerical value with decimal.

Tumor Infiltrating Lymphocytes

Select the radio button for the appropriate value for Tumor Infiltrating Lymphocytes.

Tumor Regression

Select the radio button for the appropriate value for Tumor Regression.

Mitotic Index

Select the radio button for the appropriate value for Mitotic Index.

Satellite Nodule Status

Select the radio button of the appropriate value for Satellite Nodule Status.

  • Satellite Nodule

To enter information about the Satellite Nodule, click Add More.

Site

Enter the name of the site where the satellite nodule is observed. 

Deep Melanoma Margin

To enter information about the Deep Melanoma Margin, click Add More.

  • Margin Status

Select the appropriate Margin Status from the drop-down list.

  • Margin Location

Enter the appropriate location for the deep melanoma margin in the edit box.

  • Uninvolved Margin

To enter information about the Uninvolved Margin, click the Details link.

    • Closest Distance to Tumor

Enter the distance closest to the tumor. This field accepts numerical values with decimal. Click Submit to save the data entered and to navigate back to the main form.

Lateral Melanoma Margin

To enter information about the Lateral Melanoma Margin, click the Add More button.

  • Margin Status

Select the appropriate Margin Status from the drop-down list.

  • Margin Location

Enter the appropriate location for the lateral melanoma margin in the edit box.

  • Uninvolved Margin

To enter information about the Uninvolved Margin, click the Details link.

    • Closest Distance to Tumor

Enter the distance closest to the tumor. This field accepts numerical values with decimal. Click Submit to save the data entered and to navigate back to the main form.

CNS Pathology Annotation

This annotation captures pathological details about a group of specimen collected from the Brain or spinal cord by a particular procedure.

The following table lists the attributes for the CNS Pathology Annotation.

Attribute and Sub-Form Name

Action

Specimen Procedure

Select the appropriate specimen procedure from the drop-down list.

Other Specimen Procedure

Enter the name of other Specimen Procedure if it is not available in the previous attribute's (Specimen Procedure) drop-down list. Data entry is optional.

Histologic Type

To enter information about the Histologic Type, click the Add More button.

  • Type

Select the appropriate Histologic 
Type from the drop-down list.

  • Histologic Variant Type

To enter information about the Histologic Variant Type, click the Details link. Click the Add More button to add a row.

    • Other Histologic Type

Enter the variant or Other Histologic Type. Click Submit to save the data entered and to navigate back to the main form.

Additional Finding

To enter information about the Additional Finding, click the Add More button.

  • Pathologic finding

Select the appropriate Pathologic Finding from the drop-down list.

  • Details

To enter information about the Details, click the Details link. Click Add More to add a row.

    • Details

Enter the details about the additional finding. Click Submit to save the data entered and to navigate back to the main form.

Comments

Enter any additional information about the specimen, site of specimen, or other basic details.

Histologic Grade

To enter information about the Histologic Grade, click the Add More button.

  • Grading System Name

Select the appropriate Grading System Name from the drop-down list. 

  • Other Grading System Name

Enter the name of the grading system if it is not available in the previous attribute's (Grading System Name) drop-down list. Data entry is optional.

  • Grade

Enter the Grade. This field accepts alphanumeric values.

Invasion

  • Lymphatic Invasion

Select the radio button for the appropriate value for Lymphatic Invasion.

  • Venous Invasion

Select the radio button for the appropriate value for Venous Invasion.

  • Perineural Invasion

Select the radio button for the appropriate value for Perineural Invasion.

Pathologic Staging

  • Primary Tumor Stage

To enter information about the Primary Tumor Stage, click the Enter Details link.

    • Primary Tumor Stage

Select the appropriate Primary Tumor Stage from the drop-down list.

  • Regional Lymph Node

To enter information about the Regional Lymph Node, click the Enter Details link.

    • Lymph Node Stage

Select the appropriate Lymph Node Stage from the drop-down list.

    • Number Examined

Enter the number of lymph nodes examined. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Involved

Enter the number of lymph nodes involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Positive Macroscopically

Enter the number of lymph nodes macroscopically involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Positive Microscopically

Enter the number of lymph nodes microscopically involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Matted Nodes

Select the radio button for the appropriate value for the Matted Nodes.

  • Distant Metastasis

To enter information about the Distant Metastasis, click the Enter Details link.

    • Metastasis Stage

Select the appropriate Metastasis Stage from the drop-down list.

    • Metastasis Tissue Site

To enter information about the Metastasis Tissue Site, click the Enter Details link. Click Add More to add a row.

      • Tissue Site

Select the appropriate Tissue Site from the drop-down list.

      • Other Tissue Site

Enter the name of tissue site if it is not available in the previous attribute's (Tissue Site) drop-down list. Data entry is optional.

Tumor Tissue Site

To enter information about the Tumor Tissue Site, click the Add More button.

  • Site

Select the appropriate tissue site from the drop-down list.

  • Other Site

Enter the name of tissue site if it is not available in the previous attribute's (Site) drop-down list. Data entry is optional

  • Tissue Side

To enter information about the Tissue Side, click the Details link. Click Add More to add a row.

    • Side

Select the appropriate side from the drop-down list. Click Submit to save the data entered and to navigate back to the main form.

Tumor Size

  • Greatest Dimension

Enter the greatest dimension of the tumor. This field accepts numerical values with decimal.

  • Additional Dimension One

Enter the first dimension of the tumor. This field accepts numerical values with decimal.

  • Additional Dimension Two

Enter the second dimension of the tumor. This field accepts numerical values with decimal.

  • Cannot Be Determined

Select the check box if tumor size cannot be determined, else leave un-checked. If this check box is checked the above three fields are to be left empty.

CNS Margin

  • Margin Status

Select the appropriate Margin Status from the drop-down list.

  • Margin Location

To enter information about the Tissue Side, click the Enter Details link. Click Add More to add a row.

    • Margin Location

Enter the appropriate Margin Location in the edit box.

Specimen Size

  • Greatest Dimension

Enter the Greatest Dimension of the tumor. This field accepts numerical values with decimal.

  • Additional Dimension One

Enter the first dimension of the tumor. This field accepts numerical values with decimal.

  • Additional Dimension Two

Enter the second dimension of the tumor. This field accepts numerical values with decimal.

  • Cannot Be Determined

Select the check box if the tumor size cannot be determined. If this check box is selected, do not enter data in the preceding three fields (Greatest Dimension, Additional Dimension One, and Additional Dimension Two).

Breast Pathology Annotation

This annotation captures pathological details about a group of specimen collected from the breast by a particular procedure.

The following table lists the attributes for the Breast Pathology Annotation.

Attribute and Sub-Form Name

Action

Specimen Procedure

Select the appropriate specimen procedure from the drop-down list.

Other Specimen Procedure

Enter the name of other Specimen Procedure if it is not available in the previous attribute's (Specimen Procedure) drop-down list. Data entry is optional.

Histologic Type

To enter information about the Histologic Type, click the Add More button.

  • Type

Select the appropriate Histologic 
Type from the drop-down list.

  • Histologic Variant Type

To enter information about the Histologic Variant Type, click the Details link. Click the Add More button to add a row.

    • Other Histologic Type

Enter the variant or Other Histologic Type. Click Submit to save the data entered and to navigate back to the main form.

Additional Finding

To enter information about the Additional Finding, click the Add More button.

  • Pathologic finding

Select the appropriate Pathologic Finding from the drop-down list.

  • Details

To enter information about the Details, click the Details link. Click Add More to add a row.

    • Details

Enter the details about the additional finding. Click Submit to save the data entered and to navigate back to the main form.

Comments

Enter any additional information about the specimen, site of specimen, or other basic details.

Histologic Grade

To enter information about the Histologic Grade, click the Add More button.

  • Grading System Name

Select the appropriate Grading System Name from the drop-down list. 

  • Other Grading System Name

Enter the name of the grading system if it is not available in the previous attribute's (Grading System Name) drop-down list. Data entry is optional.

  • Grade

Enter the Grade. This field accepts alphanumeric values.

Invasion

  • Lymphatic Invasion

Select the radio button for the appropriate value for Lymphatic Invasion.

  • Venous Invasion

Select the radio button for the appropriate value for Venous Invasion.

  • Perineural Invasion

Select the radio button for the appropriate value for Perineural Invasion.

Pathologic Staging

  • Primary Tumor Stage

To enter information about the Primary Tumor Stage, click the Enter Details link.

    • Primary Tumor Stage

Select the appropriate Primary Tumor Stage from the drop-down list.

  • Regional Lymph Node

To enter information about the Regional Lymph Node, click the Enter Details link.

    • Lymph Node Stage

Select the appropriate Lymph Node Stage from the drop-down list.

Number Examined

Enter the number of lymph nodes examined. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Involved

Enter the number of lymph nodes involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Positive Macroscopically

Enter the number of lymph nodes macroscopically involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Positive Microscopically

Enter the number of lymph nodes microscopically involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Matted Nodes

Select the radio button for the appropriate value for the Matted Nodes.

Distant Metastasis

To enter information about the Distant Metastasis, click the Enter Details link.

    • Metastasis Stage

Select the appropriate Metastasis Stage from the drop-down list.

    • Metastasis Tissue Site

To enter information about the Metastasis Tissue Site, click the Enter Details link. Click Add More to add a row.

      • Tissue Site

Select the appropriate Tissue Site from the drop-down list.

      • Other Tissue Site

Enter the name of tissue site if it is not available in the previous attribute's (Tissue Site) drop-down list. Data entry is optional.

Tumor Tissue Site

To enter information about the Tumor Tissue Site, click the Add More button.

  • Site

Select the appropriate tissue site from the drop-down list.

  • Other Site

Enter the name of tissue site if it is not available in the previous attribute's (Site) drop-down list. Data entry is optional

  • Tissue Side

To enter information about the Tissue Side, click the Details link. Click Add More to add a row.

    • Side

Select the appropriate side from the drop-down list. Click Submit to save the data entered and to navigate back to the main form.

Tumor Size

  • Greatest Dimension

Enter the Greatest Dimension of the tumor. This field accepts numerical values with decimal.

  • Additional Dimension One

Enter the first dimension of the tumor. This field accepts numerical values with decimal.

  • Additional Dimension Two

Enter the second dimension of the tumor. This field accepts numerical values with decimal.

  • Cannot Be Determined

Select the check box if the tumor size cannot be determined. If this check box is selected, do not enter data in the preceding three fields (Greatest Dimension, Additional Dimension One, and Additional Dimension Two).

Lymph Node Sampling

Select the appropriate Lymph Node Sampling option from the drop-down list.

Mitotic Count If Other Grading System Used

Enter the mitotic count if the grading system used is not Nottingham Histologic Score. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

Microcalcification

To enter information about the Microcalcification, click the Add More button.

  • Value

Select the appropriate value for microcalcification from the drop-down list.

Size Of Invasive Carcinoma

  • Greatest Dimension

Enter the greatest dimension of the invasive carcinoma. This field accepts numerical values with decimal.

  • Additional Dimension One

Enter the first dimension of the invasive carcinoma. This field accepts numerical values with decimal.

  • Additional Dimension Two

Enter the second dimension of the invasive carcinoma. This field accepts numerical values with decimal.

  • Cannot Be Determined

Select the check box if the invasive carcinoma size cannot be determined. If this check box is selected, do not enter data in the preceding three fields (Greatest Dimension, Additional Dimension One, and Additional Dimension Two).

Size Of Specimen

  • Greatest Dimension

Enter the greatest dimension of the Specimen. This field accepts numerical values with a decimal.

  • Additional Dimension One

Enter the first dimension of the Specimen. This field accepts numerical values with a decimal.

  • Additional Dimension Two

Enter the second dimension of the Specimen. This field accepts numerical values with a decimal.

  • Cannot Be Determined

Select the check box if the specimen size cannot be determined. If this check box is selected, do not enter data in the preceding three fields (Greatest Dimension, Additional Dimension One, and Additional Dimension Two).

Nottingham Histologic Score

Tubule Formation Score

Select the appropriate Tubule Formation Score from the drop-down list.

Nuclear Pleomorphism Score

Select the appropriate Nuclear Pleomorphism score from the drop-down list.

Mitotic Count Score

Select the appropriate Mitotic Count Score from the drop-down list.

Total Nottingham Score

Enter the sum of the three fields, namely: Tubule Formation Score, Nuclear Pleomorphism Score, and Mitotic Count Score). This field accepts integer values only. If you enter a decimal value, the value is rounded off.

Breast Margin

To enter information about the Breast Margin, click the Add More button located.

  • Margin Status

Select the appropriate Margin Status from the drop-down list.

  • Margin Location

Enter the appropriate location for the margin in the edit box. 

  • Uninvolved Margin

To enter information about the Uninvolved Margin, click the Details link.

    • Closest Distance to Tumor

Enter the distance closest to the tumor. This field accepts numerical values with a decimal. Click Submit to save the data entered and to navigate back to the main form.

  • Involved Margin

To enter information about the Involved Margin, click the Details link.

    • Extent Of Involvement

Select the appropriate Extent Of Involvement option from the drop-down list.

    • Other Extent Of Involvement

Enter the Other Extent of Involvement if it is not available in the previous attribute's (Extent of Involvement) drop-down list. Data entry is optional.

Local Excision Baseds Pathology Annotation

This annotation captures pathological details about a group of specimen collected from the colon and rectum by a procedure called Local Excision.

The following table lists the attributes for the Local Excision Based Colorectal Pathology Annotation.

Attribute and Sub-Form Name

Action

Specimen Procedure

Select the Local Excision – Transanal Disk Excision specimen procedure from the drop-down list.

Other Specimen Procedure

Leave this field blank.

Histologic Type

To enter information about the Histologic Type, click the Add More button.

  • Type

Select the appropriate Histologic 
Type from the drop-down list.

  • Histologic Variant Type

To enter information about the Histologic Variant Type, click the Details link. Click the Add More button to add a row.

    • Other Histologic Type

Enter the variant or Other Histologic Type. Click Submit to save the data entered and to navigate back to the main form.

Additional Finding

To enter information about the Additional Finding, click the Add More button.

  • Pathologic finding

Select the appropriate Pathologic Finding from the drop-down list.

  • Details

To enter information about the Details, click the Details link. Click Add More to add a row.

    • Details

Enter the details about the additional finding. Click Submit to save the data entered and to navigate back to the main form.

Comments

Enter any additional information about the specimen, site of specimen, or other basic details.

Histologic Grade

To enter information about the Histologic Grade, click the Add More button.

  • Grading System Name

Select the appropriate Grading System Name from the drop-down list. 

  • Other Grading System Name

Enter the name of the grading system if it is not available in the previous attribute's (Grading System Name) drop-down list. Data entry is optional.

  • Grade

Enter the Grade. This field accepts alphanumeric values.

Invasion

  • Lymphatic Invasion

Select the radio button for the appropriate value for Lymphatic Invasion.

  • Venous Invasion

Select the radio button for the appropriate value for Venous Invasion.

  • Perineural Invasion

Select the radio button for the appropriate value for Perineural Invasion.

Pathologic Staging

  • Primary Tumor Stage

To enter information about the Primary Tumor Stage, click the Enter Details link.

    • Primary Tumor Stage

Select the appropriate Primary Tumor Stage from the drop-down list.

  • Regional Lymph Node

To enter information about the Regional Lymph Node, click the Enter Details link.

    • Lymph Node Stage

Select the appropriate Lymph Node Stage from the drop-down list.

  • Number Examined

Enter the number of lymph nodes examined. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Involved

Enter the number of lymph nodes involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Positive Macroscopically

Enter the number of lymph nodes macroscopically involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Positive Microscopically

Enter the number of lymph nodes microscopically involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Matted Nodes

Select the radio button for the appropriate value for the Matted Nodes.

Distant Metastasis

To enter information about the Distant Metastasis, click the Enter Details link.

  • Metastasis Stage

Select the appropriate Metastasis Stage from the drop-down list.

  • Metastasis Tissue Site

To enter information about the Metastasis Tissue Site, click the Enter Details link. Click Add More to add a row.

    • Tissue Site

Select the appropriate Tissue Site from the drop-down list.

    • Other Tissue Site

Enter the name of tissue site if it is not available in the previous attribute's (Tissue Site) drop-down list. Data entry is optional.

Tumor Tissue Site

To enter information about the Tumor Tissue Site, click the Add More button.

  • Site

Select the appropriate tissue site from the drop-down list.

  • Other Site

Enter the name of tissue site if it is not available in the previous attribute's (Site) drop-down list. Data entry is optional

  • Tissue Side

To enter information about the Tissue Side, click the Details link. Click Add More to add a row.

    • Side

Select the appropriate side from the drop-down list. Click Submit to save the data entered and to navigate back to the main form.

Tumor Size

  • Greatest Dimension

Enter the Greatest Dimension of the tumor. This field accepts numerical values with decimal.

  • Additional Dimension One

Enter the first dimension of the tumor. This field accepts numerical values with decimal.

  • Additional Dimension Two

Enter the second dimension of the tumor. This field accepts numerical values with decimal.

  • Cannot Be Determined 

Select the check box if the tumor size cannot be determined. If this check box is selected, do not enter data in the preceding three fields (Greatest Dimension, Additional Dimension One, and Additional Dimension Two).

Tumor Configuration

Select the appropriate Tumor Configuration form the drop-down list.

Other Tumor Configuration

Enter the name of the tumor configuration if it is not available in the previous attribute's (Tumor Configuration) drop-down list. Data entry is optional.

Tumor Border Configuration

Select the radio button for the appropriate value for Tumor Border Configuration.

Intratumoral Peritumoral Lymphocytic Response

Select the radio button for the appropriate value for Intratumoral Peritumoral Lymphocytic Response.

Polyp Size

  • Greatest Dimension

Enter the Greatest Dimension of the polyp. This field accepts numerical values with decimal.

  • Additional Dimension One

Enter the first dimension of the polyp. This field accepts numerical values with decimal.

  • Additional Dimension Two

Enter the second dimension of the polyp. This field accepts numerical values with decimal.

  • Cannot Be Determined 

Select the check box if the polyp size cannot be determined. If this check box is selected, do not enter data in the preceding three fields (Greatest Dimension, Additional Dimension One, and Additional Dimension Two).

Specimen Integrity

  • Type

Select the radio button for the appropriate value for the specimen integrity type.

  • Number of Pieces

Enter the number of specimen pieces if fragmented. This field accepts only integer values. If you enter a decimal value, the value is rounded off.

Distance from Anal Verge

  • Distance Known

Select the check box if the distance from anal verge has been determined.

  • Length in Centimeters

Enter the distance from the anal verge in centimeters, if the previous attribute's check box is selected. This field accepts only integer values. If you enter a decimal value, the value is rounded off.

Local Excision Colorectal Deep Margin

To enter information about the Deep Margin, click the Add More button.

  • Margin Status

Select the appropriate Margin Status from the drop-down list.

  • Uninvolved Margin

To enter information about the Uninvolved Margin, click the Details link.

    • Closest Distance to Tumor

Enter the distance closest to the tumor. This field accepts numerical values with a decimal. Click Submit to save the data entered and to navigate back to the main form.

Local Excision Colorectal Lateral Margin

To enter information about the Lateral Margin, click the Add More button.

  • Margin Status

Select the appropriate Margin Status from the drop-down list.

  • Margin Location

Enter the appropriate location for the lateral margin in the edit box.

  • Uninvolved Margin

To enter information about the Uninvolved Margin, click the Details link.

    • Closest Distance to Tumor

Enter the distance closest to the tumor. This field accepts numerical values with a decimal. Click Submit to save the data entered and to navigate back to the main form.

Excisional Biopsy Based Colorectal Pathology Annotation

This annotation captures pathological details about a group of specimen collected from the colon and rectum by a particular procedure Excisional Biopsy.

The following table lists the attributes for the Excisional Biopsy Based Colorectal Pathology Annotation.

Attribute and Sub-Form Name

Action

Specimen Procedure

Select the Excisional Biopsy - Polypectomy specimen procedure from the drop-down list.

Other Specimen Procedure

Leave this field blank.

Histologic Type

To enter information about the Histologic Type, click the Add More button.

  • Type

Select the appropriate Histologic 
Type from the drop-down list.

  • Histologic Variant Type

To enter information about the Histologic Variant Type, click the Details link. Click the Add More button to add a row.

    • Other Histologic Type

Enter the variant or Other Histologic Type. Click Submit to save the data entered and to navigate back to the main form.

Additional Finding

To enter information about the Additional Finding, click the Add More button.

  • Pathologic finding

Select the appropriate Pathologic Finding from the drop-down list.

  • Details

To enter information about the Details, click the Details link. Click Add More to add a row.

    • Details

Enter the details about the additional finding. Click Submit to save the data entered and to navigate back to the main form.

Comments

Enter any additional information about the specimen, site of specimen, or other basic details.

Histologic Grade

To enter information about the Histologic Grade, click the Add More button.

  • Grading System Name

Select the appropriate Grading System Name from the drop-down list. 

  • Other Grading System Name

Enter the name of the grading system if it is not available in the previous attribute's (Grading System Name) drop-down list. Data entry is optional.

  • Grade

Enter the Grade. This field accepts alphanumeric values.

Invasion

  • Lymphatic Invasion

Select the radio button for the appropriate value for Lymphatic Invasion.

  • Venous Invasion

Select the radio button for the appropriate value for Venous Invasion.

  • Perineural Invasion

Select the radio button for the appropriate value for Perineural Invasion.

Pathologic Staging

  • Primary Tumor Stage

To enter information about the Primary Tumor Stage, click the Enter Details link.

    • Primary Tumor Stage

Select the appropriate Primary Tumor Stage from the drop-down list.

  • Regional Lymph Node

To enter information about the Regional Lymph Node, click the Enter Details link.

    • Lymph Node Stage

Select the appropriate Lymph Node Stage from the drop-down list.

    • Number Examined

Enter the number of lymph nodes examined. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Involved

Enter the number of lymph nodes involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Positive Macroscopically

Enter the number of lymph nodes macroscopically involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Positive Microscopically

Enter the number of lymph nodes microscopically involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Matted Nodes

Select the radio button for the appropriate value for the Matted Nodes.

  • Distant Metastasis

To enter information about the Distant Metastasis, click the Enter Details link.

    • Metastasis Stage

Select the appropriate Metastasis Stage from the drop-down list.

    • Metastasis Tissue Site

To enter information about the Metastasis Tissue Site, click the Enter Details link. Click Add More to add a row.

      • Tissue Site

Select the appropriate Tissue Site from the drop-down list.

      • Other Tissue Site

Enter the name of tissue site if it is not available in the previous attribute's (Tissue Site) drop-down list. Data entry is optional.

Tumor Tissue Site

To enter information about the Tumor Tissue Site, click the Add More button.

  • Site

Select the appropriate tissue site from the drop-down list.

  • Other Site

Enter the name of tissue site if it is not available in the previous attribute's (Site) drop-down list. Data entry is optional

  • Tissue Side

To enter information about the Tissue Side, click the Details link. Click Add More to add a row.

    • Side

Select the appropriate side from the drop-down list. Click Submit to save the data entered and to navigate back to the main form.

Tumor Size

 

  • Greatest Dimension

Enter the Greatest Dimension of the tumor. This field accepts numerical values with decimal.

  • Additional Dimension One

Enter the first dimension of the tumor. This field accepts numerical values with decimal.

  • Additional Dimension Two

Enter the second dimension of the tumor. This field accepts numerical values with decimal.

  • Cannot Be Determined 

Select the check box if the tumor size cannot be determined. If this check box is selected, do not enter data in the preceding three fields (Greatest Dimension, Additional Dimension One, and Additional Dimension Two).

Tumor Configuration

Select the appropriate Tumor Configuration from the drop-down list.

Other Tumor Configuration

Enter the name of the tumor configuration if it is not available in the previous attribute's (Tumor Configuration) drop-down list. Data entry is optional.

Tumor Border Configuration

Select the radio button for the appropriate value for Tumor Border Configuration.

Intratumoral Peritumoral Lymphocytic Response

Select the radio button for the appropriate value for Intratumoral Peritumoral Lymphocytic Response.

Polyp Size

  • Greatest Dimension

Enter the Greatest Dimension of the polyp. This field accepts numerical values with decimal.

  • Additional Dimension One

Enter the first dimension of the polyp. This field accepts numerical values with decimal.

  • Additional Dimension Two

Enter the second dimension of the polyp. This field accepts numerical values with decimal.

  • Cannot Be Determined 

Select the check box if the polyp size cannot be determined. If this check box is selected, do not enter data in the preceding three fields (Greatest Dimension, Additional Dimension One, and Additional Dimension Two).

Extent of Invasion

Select the appropriate Extent Of Invasion from the drop-down list.

Type of Polyp In Which Invasive Carcinoma Arose

Select the appropriate type of polyp in which the invasive carcinoma occurred.

Polyp Configuration

  • Configuration

Select the appropriate configuration type from the drop-down list.

  • Stalk Length (cm)

Enter the length of the stalk if configuration if pedunculated with stalk. This field accepts only numerical values with decimal.

Distance of Adenoma

  • Distance Known

Select the check box if the distance from anal verge has been determined.

  • Length in Centimeters

Enter the distance of adenoma from anal verge in centimeters, if the previous attribute's check box is selected. This field accepts only integer values. If you enter a decimal value, the value is rounded off.

Distance of Invasive Carcinoma

  • Distance Known

Select the check box if the distance from anal verge has been determined.

  • Length in Centimeters

Enter the distance of invasive carcinoma from anal verge in centimeters, if the previous attribute's check box is selected. This field accepts only integer values. If you enter a decimal value, the value is rounded off.

Excisional Biopsy Colorectal Deep Margin

To enter information about the Deep Margin, click the Add More button.

  • Margin Status

Select the appropriate Margin Status from the drop-down list.

  • Uninvolved Margin

To enter information about the Uninvolved Margin, click the Details link.

    • Closest Distance to Tumor

Enter the distance closest to the tumor. This field accepts numerical values with a decimal. Click Submit to save the data entered and to navigate back to the main form.

Excisional Biopsy Colorectal Lateral Margin

To enter information about the Lateral Margin, click the Add More button.

  • Margin Status

Select the appropriate Margin Status from the drop-down list

  • Uninvolved Margin

To enter information about the Uninvolved Margin, click the Details link.

    • Closest Distance to Tumor

Enter the distance closest to the tumor. This field accepts numerical values with a decimal. Click Submit to save the data entered and to navigate back to the main form.

Resection Based Colorectal Pathology Annotation

This annotation captures pathological details about a group of specimen collected from the colon and rectum by a particular procedure called Resection.

The following table lists the attributes for the Resection Based Colorectal Pathology Annotation.

Attribute and Sub-Form Name

Action

Specimen Procedure

Select the appropriate Specimen Procedure from the drop-down list.

Other Specimen Procedure

Enter the Other Specimen Procedure name if it is not available in the previous attribute's (Specimen Procedure) drop-down list. Data entry is optional.

Histologic Type

To enter information about the Histologic Type, click the Add More button.

  • Type

Select the appropriate Histologic 
Type from the drop-down list.

  • Histologic Variant Type

To enter information about the Histologic Variant Type, click the Details link. Click the Add More button to add a row.

    • Other Histologic Type

Enter the variant or Other Histologic Type. Click Submit to save the data entered and to navigate back to the main form.

Additional Finding

To enter information about the Additional Finding, click the Add More button.

  • Pathologic finding

Select the appropriate Pathologic Finding from the drop-down list.

  • Details

To enter information about the Details, click the Details link. Click Add More to add a row.

    • Details

Enter the details about the additional finding. Click Submit to save the data entered and to navigate back to the main form.

Comments

Enter any additional information about the specimen, site of specimen, or other basic details.

Histologic Grade

To enter information about the Histologic Grade, click the Add More button.

  • Grading System Name

Select the appropriate Grading System Name from the drop-down list. 

  • Other Grading System Name

Enter the name of the grading system if it is not available in the previous attribute's (Grading System Name) drop-down list. Data entry is optional.

  • Grade

Enter the Grade. This field accepts alphanumeric values.

Invasion

  • Lymphatic Invasion

Select the radio button for the appropriate value for Lymphatic Invasion.

  • Venous Invasion

Select the radio button for the appropriate value for Venous Invasion.

  • Perineural Invasion

Select the radio button for the appropriate value for Perineural Invasion.

Pathologic Staging

  • Primary Tumor Stage

To enter information about the Primary Tumor Stage, click the Enter Details link.

    • Primary Tumor Stage

Select the appropriate Primary Tumor Stage from the drop-down list.

  • Regional Lymph Node

To enter information about the Regional Lymph Node, click the Enter Details link.

    • Lymph Node Stage

Select the appropriate Lymph Node Stage from the drop-down list.

    • Number Examined

Enter the number of lymph nodes examined. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Involved

Enter the number of lymph nodes involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Positive Macroscopically

Enter the number of lymph nodes macroscopically involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Number Positive Microscopically

Enter the number of lymph nodes microscopically involved. This field accepts integer values only. If you enter a decimal value, the value is rounded off.

    • Matted Nodes

Select the radio button for the appropriate value for the Matted Nodes.

  • Distant Metastasis

To enter information about the Distant Metastasis, click the Enter Details link.

    • Metastasis Stage

Select the appropriate Metastasis Stage from the drop-down list.

    • Metastasis Tissue Site

To enter information about the Metastasis Tissue Site, click the Enter Details link. Click Add More to add a row.

      • Tissue Site

Select the appropriate Tissue Site from the drop-down list.

      • Other Tissue Site

Enter the name of tissue site if it is not available in the previous attribute's (Tissue Site) drop-down list. Data entry is optional.

Tumor Tissue Site

To enter information about the Tumor Tissue Site, click the Add More button.

  • Site

Select the appropriate tissue site from the drop-down list.

  • Other Site

Enter the name of tissue site if it is not available in the previous attribute's (Site) drop-down list. Data entry is optional

  • Tissue Side

To enter information about the Tissue Side, click the Details link. Click Add More to add a row.

    • Side

Select the appropriate side from the drop-down list. Click Submit to save the data entered and to navigate back to the main form.

Tumor Size

  • Greatest Dimension

Enter the Greatest Dimension of the tumor. This field accepts numerical values with decimal.

  • Additional Dimension One

Enter the first dimension of the tumor. This field accepts numerical values with decimal.

  • Additional Dimension Two

Enter the second dimension of the tumor. This field accepts numerical values with decimal.

  • Cannot Be Determined 

Select the check box if the tumor size cannot be determined. If this check box is selected, do not enter data in the preceding three fields (Greatest Dimension, Additional Dimension One, and Additional Dimension Two).

Tumor Configuration

Select the appropriate Tumor Configuration form the drop-down list.

Other Tumor Configuration

Enter the name of the tumor configuration if it is not available in the previous attribute's (Tumor Configuration) drop-down list. Data entry is optional.

Tumor Border Configuration

Select the radio button for the appropriate value for the Tumor Border Configuration.

Intratumoral Peritumoral Lymphocytic Response

Select the radio button for the appropriate value for the Intratumoral Peritumoral Lymphocytic Response.

Polyp Size

  • Greatest Dimension

Enter the Greatest Dimension of the polyp. This field accepts numerical values with decimal.

  • Additional Dimension One

Enter the first dimension of the polyp. This field accepts numerical values with decimal.

  • Additional Dimension Two

Enter the second dimension of the polyp. This field accepts numerical values with decimal.

  • Cannot Be Determined 

Select the check box if the polyp size cannot be determined. If this check box is selected, do not enter data in the preceding three fields (Greatest Dimension, Additional Dimension One, and Additional Dimension Two).

Specimen Length (cm)

Enter the length of specimen in centimeters. This field accepts numerical values with decimal.

Intactness of Mesorectum

Select the radio button for the appropriate value for Quantifying Intactness Of Mesorectum.

Radial Margin

To enter information about the Radial Margin, click the Add More button.

  • Margin Status

Select the appropriate Margin Status from the drop-down list.

  • Uninvolved Margin

To enter information about the Uninvolved Margin, click the Details link.

    • Margin Location

Enter the appropriate Margin Location in the edit box.

    • Closest Distance to Tumor

Enter the distance closest to the tumor. This field accepts numerical values with a decimal. Click Submit to save the data entered and to navigate back to the main form.

Mesentric Margin

To enter information about the Mesentric Margin, click the Add More button.

  • Margin Status

Select the appropriate Margin Status from the drop-down list.

  • Uninvolved Margin

To enter information about the Uninvolved Margin, click the Details link.

    • Margin Location

Enter the appropriate Margin Location in the edit box.

    • Closest Distance to Tumor

Enter the distance closest to the tumor. This field accepts numerical values with a decimal. Click Submit to save the data entered and to navigate back to the main form.

Distal Margin

To enter information about the Distal Margin, click the Add More button.

  • Margin Status

Select the appropriate Margin Status from the drop-down list.

  • Uninvolved Margin

To enter information about the Uninvolved Margin, click the Details link.

    • Margin Location

Enter the appropriate Margin Location in the edit box.

    • Closest Distance to Tumor

Enter the distance closest to the tumor. This field accepts numerical values with decimal. Click Submit to save the data entered and to navigate back to the main form.

Proximal Margin

To enter information about the Proximal Margin, click the Add More button.

  • Margin Status

Select the appropriate Margin Status from the drop-down list.

  • Uninvolved Margin

To enter information about the Uninvolved Margin, click the Details link.

    • Margin Location

Enter the appropriate Margin Location in the edit box.

    • Closest Distance to Tumor

Enter the distance closest to the tumor. This field accepts numerical values with a decimal. Click Submit to save the data entered and to navigate back to the main form.

Pathology-Specimen Clinical Annotation

This section outlines the following annotations based on specimens:

Specimen Based Solid Tissue Pathology Annotation

This generic annotation captures the pathological details about a specimen collected from any organ in the body.

The following table lists the attributes for the Specimen Based Solid Tissue Pathology Annotation.

Attribute and Sub-Form Name

Action

Histologic Type

To enter information about the Histologic Type, click the Add More button.

Type

Select the appropriate Histologic Type from the drop-down list.

Histologic Variant Type

To enter information for the Histologic Variant Type, click the Details link. Click the Add More to add a row.

Other Histologic Type

Enter the variant or other Histologic Type. Click Submit to save the data entered and to navigate back to the main form.

Additional Finding

To enter information about the Additional Finding, click the Add More button.

Pathologic finding

Select the appropriate pathologic finding from the drop-down list. 

Details

To enter information about the Details, click the Details link. Click Add More to add a row.

Details

Enter the details about the additional finding. Click Submit to save the data entered and to navigate back to the main form.

Histologic Grade

To enter information for the Histologic Grade, click the Add More button.

Grading System Name

Select the appropriate Grading System Name from the drop-down list.

Other Grading System Name

Enter the name of grading system if the same is not available in the previous attribute's (Grading System Name) drop-down list, else leave it blank.

Grade

Enter the Grade. This field accepts alphanumeric values.

Invasion

Lymphatic Invasion

Select the radio button for the appropriate value for Lymphatic Invasion.

Venous Invasion

Select the radio button for the appropriate value for Venous Invasion.

Perineural Invasion

Select the radio button for the appropriate value for Perineural Invasion.

Comments

Enter any additional information about the specimen, site of specimen, or other basic details.

Note

To add more than one row for spreadsheet type of sub-form, click Add More. To delete rows, select the check box next to the row and click Delete.

 

Colorectal Specimen Pathology Annotation

This organ specific annotation captures the pathological details about the specimen collected from colon or rectum.

The following table lists the attributes for the Colorectal Specimen Pathology Annotation.

Attribute and Sub-Form Name

Action

Histologic Type

To enter information about the Histologic Type, click the Add More button.

  • Type

Select the appropriate Histologic Type, from the drop-down list. 

  • Histologic Variant Type

To enter information about the Histologic Variant Type, click the Details Link. Click the Add More button to add a record.

    • Other Histologic Type

Enter the variant or Other Histologic Type. Click Submit to save the data entered and to navigate back to the main form.

Additional Finding

To enter information about the Additional Finding, click the Add More button.

  • Pathologic finding

Select the appropriate Pathologic Finding from the drop-down list.

  • Details

To enter information about the Details, click the Details link. Click Add More to add a record.

    • Details

Enter the details about the additional finding. Click Submit to save the data entered and to navigate back to the main form.

Histologic Grade

To enter information about the Histologic Grade, click the Add More button.

  • Grading System Name

Select the appropriate grading system name from the drop-down list.

  • Other Grading System Name

Enter the name of grading system if same is not available in the previous attribute's (Grading System Name) drop-down list, else leave it blank.

  • Grade

Enter the Grade. This field accepts alphanumeric values.

Invasion

  • Lymphatic Invasion

Select the radio button for the appropriate value for Lymphatic Invasion.

  • Venous Invasion

Select the radio button for the appropriate value for Venous Invasion.

  • Perineural Invasion

Select the radio button for the appropriate value for Perineural Invasion.

Comments

Enter any additional information about the specimen, site of specimen, or other basic details.

Tumor Border Configuration

Select the appropriate configuration for the tumor border from the drop-down list.

Intratumoral Peritumoral Lymphocytic Response

Select the appropriate lymphocytic response from the drop-down list.

Specimen Pathology Annotation

This organ-specific annotation captures the pathological details about the specimen collected from pancreas.

The following table lists the attributes for the Pancreas Specimen Pathology Annotation.

Attribute and Sub-Form Name

Action

Histologic Type

To enter information about the Histologic Type, click the Add More button.

  • Type

Select the appropriate Histologic Type from the drop-down list.

  • Histologic Variant Type

To enter information for the Histologic Variant Type, click the Details Link. Click Add More to add a record.

    • Other Histologic Type

Enter the variant or Other Histologic Type. Click Submit to save the data entered and to navigate back to the main form.

Additional Finding

To enter information about the Additional Finding, click the Add More button.

  • Pathologic Finding

Select the appropriate Pathologic Finding from the drop-down list.

  • Details

To enter information about the Details, click the Details link. Click the Add More button to add a row.

    • Details

Enter the details about the additional finding. Click Submit to save the data entered and to navigate back to the main form.

Histologic Grade

To enter information about the Histologic Grade, click the Add More button.

  • Grading System Name

Select the appropriate grading system name from the drop-down list.

  • Other Grading System Name

Enter the name of grading system if the same is not available in the previous attribute's (Grading System Name) drop-down list, else leave it blank.

  • Grade

Enter the Grade. This field accepts alphanumeric values.

Invasion

  • Lymphatic Invasion

Select the radio button for the appropriate value for Lymphatic Invasion.

  • Venous Invasion

Select the radio button for the appropriate value for Venous Invasion. 

  • Perineural Invasion

Select the radio button for the appropriate value for Perineural Invasion.

Comments

Enter any additional information about the specimen, site of specimen, or other basic details.

Melanoma Specimen Pathology Annotation

This organ-specific annotation captures the pathological details about the specimen collected from skin.

The following table lists the attributes for the Melanoma Specimen Pathology Annotation.

Attribute and Sub-Form Name

Action

Histologic Type

To enter information about the Histologic Type, click the Add More button.

  • Type

Select the appropriate Histologic Type from the drop-down list.

  • Histologic Variant Type

To enter information about the Histologic Variant Type, click the Details link. Click Add More to add a row.

    • Other Histologic Type

Enter the variant or other Histologic Type. Click Submit to save the data entered and to navigate back to the main form.

Additional Finding

To enter information about the Additional Finding, click the Add More button.

  • Pathologic finding

Select the appropriate pathologic finding, from the drop-down list.

  • Details

To enter information about the Details, click the Details link. Click Add More to add a row.

    • Details

Enter the details about the additional finding. Click Submit to save the data entered and to navigate back to the main form.

Histologic Grade

To enter record for the Histologic Grade, click the Add More button.

  • Grading System Name

Select the appropriate grading system name from the drop-down list.

  • Other Grading System Name

Enter the name of grading system if same is not available in the previous attribute's (Grading System Name) drop-down list, else leave it blank. 

  • Grade

Enter the Grade. This field accepts alphanumeric values.

Invasion

  • Lymphatic Invasion

Select the radio button for the appropriate value for Lymphatic Invasion.

  • Venous Invasion

Select the radio button for the appropriate value for Venous Invasion.

  • Perineural Invasion

Select the radio button for the appropriate value for Perineural Invasion.

Comments

Enter any additional information about the specimen, site of specimen, or other basic details.

Ulceration

Select the radio button for the appropriate value for the Ulceration.

Depth of Invasion Cannot be determined

Select the check box if the depth of invasion cannot be determined.

Depth of Invasion

Enter the value for Depth of Invasion, if determined. This field accepts numerical value with decimal.

Tumor Infiltrating Lymphocytes

Select the radio button for the appropriate value for Tumor Infiltrating Lymphocytes.

Tumor Regression

Select the radio button for the appropriate value for Tumor Regression. 

Mitotic Index

Select the radio button for the appropriate value for Mitotic Index.

CNS Specimen Pathology Annotation

This organ-specific annotation captures the pathological details about the specimen collected from the central nervous system.

The following table lists the attributes for the CNS Specimen Pathology Annotation.

Attribute and Sub-Form Name

Action

Histologic Type

To enter information about the Histologic Type, click the Add More button.

  • Type

Select the appropriate Histologic Type from the drop-down list.

  • Histologic Variant Type

To enter information about the Histologic Variant Type, click the Details Link. Click the Add More button to add a row. 

    • Other Histologic Type

Enter the variant or other Histologic Type. Click Submit to save the data entered and to navigate back to the main form.

Additional Finding

To enter information about the Additional Finding, click the Add More button.

  • Pathologic finding

Select the appropriate Pathologic Finding from the drop-down list.

  • Details

To enter information about the Details, click the Details link. Click the Add More button to add a row.

    • Details

Enter the details about the additional finding. Click Submit to save the data entered and to navigate back to the main form.

Histologic Grade

To enter information about the Histologic Grade, click the Add More button.

  • Grading System Name

Select the appropriate Grading System Name from the drop-down list.

  • Other Grading System Name

Enter the name of grading system if the same is not available in the previous attribute's (Grading System Name) drop-down list, else leave it blank.

Grade

Enter the Grade. This field accepts alphanumeric values.

Invasion

 

  • Lymphatic Invasion

Select the radio button for the appropriate value for Lymphatic Invasion.

  • Venous Invasion

Select the radio button for the appropriate value for Venous Invasion.

  • Perineural Invasion

Select the radio button for the appropriate value for Perineural Invasion. 

Comments

Enter any additional information about the specimen, site of specimen, or other basic details.

Prostate Specimen Pathology Annotation

This organ-specific annotation captures the pathological details about the specimen collected from the prostate.

The following table lists the attributes for the Prostate Specimen Pathology Annotation.

Attribute and Sub-Form Name

Action

Histologic Type

To enter information about the Histologic Type, click the Add More button.

  • Type

Select the appropriate Histologic Type from the drop-down list.

  • Histologic Variant Type

To enter information about the Histologic Variant Type, click the Details link. Click the Add More button to add a row.

    • Other Histologic Type

Enter the variant or other Histologic Type. Click Submit to save the data entered and to navigate back to the main form.

Additional Finding

To enter information about the Additional Finding, click the Add More button.

  • Pathologic finding

Select the appropriate Pathologic Finding from the drop-down list.

  • Details

To enter information about the Details, click the Details link. Click the Add More button to add a record.

    • Details

Enter the details about the additional finding. Click Submit to save the data entered and to navigate back to the main form.

Histologic Grade

To enter information about the Histologic Grade, click the Add More button. 

  • Grading System Name

Select the appropriate Grading System Name from the drop-down list.

  • Other Grading System Name

Enter the name of grading system if the same is not available in the previous attribute's (Grading System Name) drop-down list, else leave it blank.

  • Grade

Enter the Grade. This field accepts alphanumeric values.

Invasion

  • Lymphatic Invasion

Select the radio button for the appropriate value for Lymphatic Invasion.

  • Venous Invasion

Select the radio button for the appropriate value for Venous Invasion.

  • Perineural Invasion

Select the radio button for the appropriate value for perineural invasion.

Comments

Enter any additional information about the specimen, site of specimen, or other basic details.

Proportion Or Percent Of Prostatic Tissue Involved By Tumor

Enter the percentage of prostatic tissue involved by tumor. This field accepts numerical value with decimal between the range (0.0,100.0).

Gleason Score

  • Primary Pattern Score

Select the appropriate Primary Pattern Gleason Score from the drop-down list.

  • Secondary Pattern Score

Select the appropriate Secondary Pattern Gleason Score from the drop-down list.

  • Tertiary Pattern Score

Select the appropriate Tertiary Pattern Gleason Score from the drop-down list.

Kidney Specimen Pathology Annotation

This organ-specific annotation captures the pathological details about the specimen collected from Kidney.

The following table lists the attributes for the Kidney Specimen Pathology Annotation.

Attribute and Sub-Form Name

Action

Histologic Type

To enter information about the Histologic Type, click the Add More button.

  • Type

Select the appropriate Histologic Type from the drop-down list.

  • Histologic Variant Type

To enter information about the Histologic Variant Type, click the DETAILS link. Click the Add More button to add a row.

    • Other Histologic Type

Enter the variant or other Histologic Type. Click the Submit button save the data entered and to navigate back to the main form.

Additional Finding

To enter information about the Additional Finding, click the Add More button. 

  • Pathologic finding

Select the appropriate Pathologic Finding from the drop-down list.

  • Details

To enter information about the Details, click the Details link. Click the Add More button to add a row.

    • Details

Enter the details about the additional finding. Click Submit to save the data entered and to navigate back to the main form.

Histologic Grade

To enter information about the Histologic Grade, click the Add More button.

  • Grading System Name

Select the appropriate Grading System Name from the drop-down list.

  • Other Grading System Name

Enter the name of grading system if the same is not available in the previous attribute's (Grading System Name) drop-down list, else leave it blank.

  • Grade

Enter the Grade. This field accepts alphanumeric values.

Invasion

  • Lymphatic Invasion

Select the radio button for the appropriate value for Lymphatic Invasion.

  • Venous Invasion

Select the radio button for the appropriate value for Venous Invasion.

  • Perineural Invasion

Select the radio button for the appropriate value for Perineural Invasion.

Comments

Enter any additional information about the specimen, site of specimen, or other basic details.

Lung Specimen Pathology Annotation

This organ-specific annotation captures the pathological details about the specimen collected from Lung.

The following table lists the attributes for the Lung Specimen Pathology Annotation.

Attribute and Sub-Form Name

Action

Histologic Type

To enter information about the Histologic Type, click the Add More button.

  • Type

Select the appropriate Histologic Type from the drop-down list.

  • Histologic Variant Type

To enter information about the Histologic Variant Type, click the Details link. Click the Add More button to add a row.

    • Other Histologic Type

Enter the variant or Other Histologic Type. Click Submit to save the data entered and to navigate back to the main form.

Additional Finding

To enter more information about the Additional Finding, click the Add More button.

  • Pathologic finding

Select the appropriate Pathologic Finding from the drop-down list. 

  • Details

To enter information about the Details, click the Details link. Click the Add More button to add a row.

    • Details

Enter the details about the additional finding. Click Submit to save the data entered and to navigate back to the main form.

Histologic Grade

To enter information about the Histologic Grade, click the Add More button.

  • Grading System Name

Select the appropriate Grading System Name from the drop-down list.

  • Other Grading System Name

Enter the name of grading system if the same is not available in the previous attribute's (Grading System Name) drop-down list, else leave it blank.

  • Grade

Enter the Grade. This field accepts alphanumeric values.

Invasion

  • Lymphatic Invasion

Select the radio button for the value appropriate for Lymphatic Invasion.

  • Venous Invasion

Select the radio button for the value appropriate for Venous Invasion.

  • Perineural Invasion

Select the radio button for the value appropriate for Perineural Invasion.

Comments

Enter any additional information about the specimen, site of specimen, or other basic details.

Breast Specimen Pathology Annotation

This organ-specific annotation captures the pathological details about the specimen collected from the breast.

The following table lists the attributes for the Breast Specimen Pathology Annotation.

Attribute and Sub-Form Name

Action

Histologic Type

To enter information about the Histologic Type, click the Add More button.

  • Type

Select the appropriate Histologic Type, from the drop-down list.

  • Histologic Variant Type

To enter information about the Histologic Variant Type, click the Details link. Click the Add More button to add a record.

    • Other Histologic Type

Enter the variant or other Histologic Type. Click Submit to save the data entered and to navigate back to the main form.

Additional Finding

To enter information about the Additional Finding, click the Add More button.

  • Pathologic finding

Select the appropriate Pathologic Finding, from the drop-down list.

  • Details

To enter information about the Details, click the Details link. Click Add More to add a row.

    • Details

Enter the details about the additional finding. Click Submit to save the data entered and to navigate back to the main form.

Histologic Grade

To enter information about the Histologic Grade, click the Add More button.

  • Grading System Name

Select the appropriate grading system name from the drop-down list.

  • Other Grading System Name

Enter the name of grading system if the same is not available in the previous attribute's (Grading System Name) drop-down list, else leave it blank.

  • Grade

Enter the Grade. This field accepts alphanumeric values.

Invasion

  • Lymphatic Invasion

Select the radio button for the value appropriate for the Lymphatic Invasion.

  • Venous Invasion

Select the radio button for the value appropriate for the Venous Invasion.

  • Perineural Invasion

Select the radio button for the value appropriate for the Perineural Invasion.

Comments

Enter any additional information about the specimen, site of specimen, or other basic details.

Mitotic Count if Other Grading System Name Used

Enter the mitotic count if the grading system used is not Nottingham Histologic Score. This field accepts integer values only. If you enter a decimal value, then the value is rounded off.

Nottingham Histologic Score

Enter the values in this field if the grading system is Nottingham Histologic Grading system.

  • Tubule Formation Score

Select the appropriate Tubule Formation Score from the drop-down list.

  • Nuclear Pleomorphism Score

Select the appropriate Nuclear Pleomorphism Score from the drop-down list. 

  • Mitotic Count Score

Select the appropriate Mitotic Count Score from the drop-down list.

  • Total Nottingham Score

Enter the sum total of the (tubule formation score + nuclear pleomorphism score + mitotic count score). This field accepts integer values only. If you enter a decimal value, then the value is rounded off.