1ADMINISTRATIVE PARTPROCARE – prospective registration

OPERATIVE DATA ENTRY FORM

Registration number, provided by the data centre:

PART I: PRE-treatment data

1 Date of first consultation or hospitalisation for rectal cancerREQ

(dd/mm/yyyy):

2 Lower limit primary tumour:cm above the margo aniREQ

Please, indicate what reference was used if not the anal verge (margo ani)

based on:

rigid rectoscopy (to be preferred)

coloscopy (during withdrawal of the coloscopy)

3 Characteristics of the primary tumour

LocalisationREQ:

Ventral

Lateral left

Lateral right

Dorsal

Upper limit cm (if possible, in cm above the margo ani)

Clinical

Mobile

Fixed

Not palpable

4Staging procedures and clinical TNM (UICC 2002)

Check all staging procedures that were carried out.

Rx thoraxyesno

US liver/abdomenyesno

CT:

  • Thorax:yesno
  • Abdomen: yesno
  • Pelvis: yesno

If yes: cT:

cN:

cCRM lateral or circumferential margin:mm

MRI:yesno

If yes: cT:

cN:

cCRM lateral or circumferential margin:mm

involvement of the sphincters : yesno

TRUS:yesno

If yes: cT:

cN:

involvement of the sphincters : yesno

PETyesno

PET/CTyesno

Otheryesno

If yes, please specifiy:

cMREQ

No metastasis

Non-mesorectal nodes

Liver

Peritoneum

Lung

Bone

Other, please specify:

Summary cTNM stageREQ: cTNM

5 CEA serum before treatmentREQ:

6 Coloscopy

Total coloscopyREQ

Yes
simultaneous lesions?

No

Polyp

Carcinoma

Other

No

Reason?

Tumour stenosis

Insufficient preparation

Intolerance of the patient

Technical reasons

Other

Biopsy of the tumour

YesDate of biopsyREQ (dd/mm/yyyy): … / … / …

Result of the biopsy (specify):

Adenocarcinoma

Other:

No

Complications

No

Yes:

  • Over sedationyesno
  • Bleedingyesno
  • Perforationyesno
  • Otheryesno

If yes, please specifiy:

7 Double contrast barium enema

No

Yes

 Barium Gastrografine

 Complete Incomplete (incompl. visualisation of the entire colon)

8Virtual colonoscopy

No

Yes

simultaneous lesions?

No

Polyp

Carcinoma

Other

9. Anorectal function before treatment

Continent?REQ

Yes

No

Daily frequency of defaecation:

Use of drugs/medication for defaecation (incl. enema)

No

Yes

10. Urogenital function before treatment

Urinary function

Continent?

Yes

No

Sexual function

Non active

Active

Male:

Normal

Incomplete erection

Absent ejaculation

Absent orgasm

Not known

Female:

Normal

Dyspareunia

Absent orgasm

Not known

1SURGICAL FORM – preop dataPROCARE – prospective registration

1FOLLOW UP FORMPROCARE – prospective registration