Colon Cancer-Pathology Requisition
 

Colorectal Ca Pathology Requisition

SURGEON NAME: _________________________                       PATIENT ID INFORMATION

DATE OF OPERATION: _____/_______/_______

                                                   (mm/dd/yyyy)

SOURCE OF SPECIMEN:  

A:__________________________________________

B:__________________________________________

C:__________________________________________

D:__________________________________________

 

HISTORY:

   Previous Colon Adenoma or Carcinoma

 

    Inflammatory Bowel Disease:

   Familial polyposis:  Type 

 FAP      HNPCC    ______________Other

  Ulcerative Colitis

Related Pathology:

 Yes

Hospital:_____________________

 

  Crohn’s Disease

 

 No

 

 

 

 

Malignant Polyp:

 Partial Removal

 Complete

 

 

 

   No Relevant History

 

 

 

 

   Other Relevant History     _______________________________________________________________________

 

NEOADJUVANT THERAPY:

 Yes

XRT:

         Short Course

 Long Course

 Chemo

 

  No

 

  Unknown

Clinical Staging  T__________________N_____________________M___________________

(Pretreatment clinical staging)

 

SURGICAL TECHNIQUE:

 Laparoscopic

  Open

   Transanal

 

PROCEDURE

TUMOUR SITE

  Colectomy:

  Single

  Multiple

 

  Left

  Total Abdominal

 

 

  Right

  Transverse

  Cecum

  Rectosigmoid -

  Sigmoidectomy

  Right (ascending) Colon

 

 1. Above the sacral promontory

  Anterior Resection

  Hepatic Flexure

 

 2. Between 1 and 3

  Abdominoperineal Resection

  Transverse Colon

 

 3. Below the anterior peritoneal reflection

  Total Proctocolectomy

  Splenic flexure

  Rectum

For Rectal Procedures Only:

  Left (descending) Colon

  Other

Mesorectal Excision:

  Sigmoid Colon

 

  Total

 

 

 

Tumour appropriate mesorectal margin (min 5 cm)

 

 

  No

 

 

ORIENTATION OF SPECIMEN:

  Suture Marking:

_______________Proximal Margin_________________Distal Margin

 

  Other Suture Marking (if necessary eg. soft tissue margin)___________________________________

 

 

O.R. Nurse __________________     Spec. No. _________________         Entered By: _____________________

 

MET

MQ

JF

NAR

RJ

WH

MS

NM

Jar

P

C

Lev

SS

Dis

Decal

Comment / Prev

Pathol Notified