Data Collection Form - Sgo Page 2
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3ENDOMETRIAL CANCER OPERATIVE CARE AND POSTOP COMPLICATIONS WITHIN 30 DAYS
DATA COLLECTION FORM CONTINUED
V. SURGICAL PATHOLOGY
FIGO Stage:
IA
IB
II
IIIA
IIIB
IIIC1
IIIC2
IVA
IVB
Recurrent
FIGO Grade:
1
2
3
Number of Right Nodes Removed
Number of Left Nodes Removed
TOTALS (calculated field)
Pelvic Lymphadenectomy:
Yes
No
Number of Right Nodes Positive
Number of Left Nodes Positive
TOTALS (calculated field)
If Yes, Provide Information
Paraaortic Lymphadenectomy:
Total Number Removed
Total Number Positive
Yes
No
If Yes, Provide Information
Yes
No
H & E Positive:
Microstaged Positive:
Yes
No
If SLN positive, was Ultra Staging
Sentinel Lymph Node:
Yes
No
Performed?
Yes
No
Positive:
Yes
No
Isolated (ITC) Positive:
Yes
No
If Yes, Provide Information:
If Yes, Select:
Micromets Positive:
Yes
No
Macromets Positive:
Yes
No
VI. SURGERY
National Provider Identifier:
Date of Surgery:
Surgeon Specialty:
Gynecologic Oncology
Obstetrics and Gynecology
General Surgery
Other
Contraindication:
Yes
No
Minimally Invasive Surgery Offered:
Yes
No
Surgical Approach:
Vaginal
Laparotomy
Laparoscopy/Laparoscopic-assisted
Robotic-assisted
If Yes, Select:
Did patient covert to Laparotomy?
Large BMI
Extension Adhesion
Other
Yes
No
Large Uterus
Anesthesia or Insufflation Related Problems
N/A
Below Pelvic Brim
Small Bowel Serosa/Mensentery
Extent of Cancer: (if stage IV):
Diaphragm
Spleen
Liver
Carcinomatosis (>50% of all peritoneal surfaces involved by tumor)
Previous hysterectomy:
If yes, date: ______ (only year needed)
Yes
No
Hysterectomy Type I
Hysterectomy Type II
Hysterectomy Type III
Operation:
USO/BSO
Omentectomy
Other
PA Lymphadenectomy
Pelvic Lymphadenectomy
Uterine weight (in grams):
_______________________
If Yes, Select:
Operative Note Completed/Present
(within 48 hours of Operation)
No Gross Residual Disease
Less Than 1 cm of Residual Disease
Yes
No
Residual Disease Not Documented
Greater Than or Equal to 1 cm of Residual Disease
Largest Diameter of Residual Disease (cm)
Estimated Blood Loss (ml)
OR Entry Time: __________________________(24 hr. clock)
Skin Incision Start Time: __________________(24 hr. clock)
Skin Incision Stop Time: __________________(24 hr. clock)
OR Exit Time: ___________________________(24 hr. clock)
1192SGO-0825
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