Appendices
Copy of registration forms used in the MoMaTEC trials;
#4 Inclusion form
#5 Follow-up form
#4 Inclusion form revised after introduction of FIGO 2009 classification
#5 Follow-up form revised after introduction of FIGO 2009 classification
Study of prognostic markers in endometrial cancer curettage
Registration– clinical data at primary treatment
Parity (no. of births): Patients date of birth month year Menopausal status:
pre- (1) peri- (2) postmenopausal(3)
Primary treatment
date for primary surgery:hyst. with salpingoophorectomi (1) palliative tumour reduction (2) curettage only (3) Lymphadenectomy: yes(1) no (2) no. of lymph nodes removed
Additional treatment as a part of primary treatment:
no (0)
external radiation(1) internal radiation(2) chemotherapy(3) hormonal treatment (4) chemotherapy +radiation(5) other(9) Supplementary information:________________________________________
Surgical FIGO stage (1988 criterias including histopathologic evaluation)
: FIGO I (10) FIGO IA (11) FIGO IB (12) FIGO IC (13)FIGO II (20) FIGO IIA (21) FIGO IIB (22)
FIGO III (30) FIGO IIIA (31) FIGO IIIB (32) FIGO IIIC (33) FIGO IV (40) FIGO IVA (41) FIGO IVB (42)
Histopathologic results:
Histologic subtype:
endometrioid(1) adenosq.(2) clear cell(3) serous pap.(4) other(6) hyperplasia(5) Histologic grade:
high (grade 1, well differentiated)(1) medium (grade 2) (2) low (grade 3, poorly diff.) (3) Lymph node metastases, histologically verified:
yes(1) no (2) Number of positive lymph nodes
__________________________ __________________________ _________________________
# 4
in endometrialcancer curettage
Contact info: Professor Helga B Salvesen, e-post: [email protected]
Avdelingsingeniør Britt Edvardsen, e-post: [email protected]
Registration– clinical follow-up
Recurrence:
Yes (1) no (2)
Date of recurrence
:
Location of recurrence: pelvic (1) distant metastases (2), where?_________________
Treatment of recurrence
No (0)
external radiation (1) internal radiation (2) chemotherapy (3) Hormonal treatment (4) chemotherapy +radiation (5) other (9)
Additional
information:_____________________________________________________________________
______________________________________________________________________________
Status at last follow-up:
Date for last follow-up information:
Alive and well (1)
Alive with active disease (2) Dead from other causes (3)
Dead with but not due to active disease (4) Dead from disease (5)
__________________________
Place, date
__________________________
Signature physician
_________________________
Name physician in print
# 5
Study of prognostic markers in endometrial cancer curettage
Registration – clinical data at primary treatment
Parity (no. of births): Patient’s date of birth month year Menopausal status:
pre- (1) peri- (2) postmenopausal(3)
Curettings histology:
low risk (1)* high risk (2)***low risk: benign, hyperplasia, endometrioid grade 1-2.
**High risk: serous-papillary, clear cell, carcinocarcoma,endometrioid grade 3, undifferentiated
Primary treatment
date of primary surgery:hyst. with salpingoophorectomi (1) palliative tumour reduction (2) curettage only (3) Lymphadenectomy: pelvic(1) paraaortic (2) not performed (3) no.nodes removed
Additional treatment as a part of primary treatment
:none (0) external radiation (+/- internal)(1) internal radiation(2) chemotherapy(3) hormonal treatment (4) chemotherapy +radiation(5) other(9)
Supplementary information/ type of chemotherapy:___________________________
Surgical FIGO stage (2009 criteria including histopathologic evaluation)
: FIGO I (10) FIGO IA (11) FIGO IB (12) FIGO IC (13) FIGO II (20)FIGO III (30) FIGO IIIA (31) FIGO IIIB (32) FIGO IIIC1 (33) FIGO IIIC2 (34) FIGO IV (40) FIGO IVA (41) FIGO IVB (42)
Histopathologic results:
Depth of myometrial infiltration:
<50% (1) >50% (2)Histologic subtype:
endometrioid(1) adenosq.(2) clear cell(3) serous pap.(4) carcinosarcoma(6) hyperplasia(5) undifferentiated/other (7)Histologic grade:
grade 1, well differentiated(1) grade 2 (2) grade 3, poorly diff.(3)Lymph node metastases histologically verified:
yes(1) no (2) not applicable (0) Number of positive lymph nodes__________________________ __________________________ _________________________
# 4
in endometrial cancer curettings
Contact info: Professor Helga B Salvesen, e-post: [email protected]
Avdelingsingeniør Britt Edvardsen, e-post: [email protected]
month/year Study ID Initials of birth
Registration– clinical follow-up Latest follow-up
Recurrence:
yes (1) no (2) progression/ non radically operated (3) Date of recurrence/progression:
Localisation: vaginal vault (3) other pelvic (4) distant metastases (2) If distant; where?__________________________________
Confirmation by histology:
yes (1) no (2)Treatment of recurrence/ progression:
None (0)
external radiation (+/- internal) (1) internal radiation (2) chemotherapy (3) Hormonal treatment (4)
chemotherapy + radiation (5) other (9) Additional information/type of chemotherapy:
_______________________________________________________________________________
Status at latest follow-up:
Date of latest follow-up:
alive, without recurrence of endometrial cancer (1) alive, with known recurrence of endometrial cancer (2) dead from other causes than endometrial cancer (3) dead with, but not due to, endometrial cancer (4) dead from endometrial cancer (5)
__________________________
Place, date
__________________________
Signature physician
_________________________
Name physician in print
