Here is a standard signature template that you can use as a type of checklist of items that probably should be included in your signature.
Your task now is to go through your available prior documents (i.e, colonoscopy procedure report, colonoscopy biopsy report, both pre- and post-treatment scan reports, baseline blood test results, follow-up blood test results, special test results, if any, (e.g., genomic or genetic tests), to search for the important missing data fields.
The overall objective at this point in time is to create a signature that shows your DH's complete risk-factor profile before treatment ever commenced (i.e., before neo-adjuvant therapy, before surgery, and before adjuvant therapy). This defines your husband's risk profile at the time of highest risk, and this is what the doctors focus on when designing a first-line treatment plan.
The items that are most important now are indicated in bold face type. The items that seem to be missing in your current signature are highlighted in red
This task may be a bit difficult for you because the necessary data points are typically found in a variety of different places and may be phrased in unusual, non-standard vocabulary. And some of them may actually be missing because they were never done.
At the bottom of this post I have put some numbered comments that may help you in locating the required elements for the data points in question (if they in fact exist in your dossier of reports).
You may eventually have to have a special meeting with your oncologist where you bring your dossier of reports and ask him to help you find the specific important missing items that should be in your signature.
O Stoma Mia wrote:
Some items that you could include in your signature are given below:
- Age & Sex
- DX: Rectal Cancer (RC) or Colon Cancer (CC)
- Tumor Location: If RC, then upper, middle or lower rectum, and distance from anal verge (AV). If CC, then cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, sigmoid colon, or recto-sigmoid junction, etc.
- Tumor type: Adenocarcinoma; villous adenoma; signet ring-cell carcinoma, etc.
- Tumor size(in mm or cm)
- Tumor grade:
G1: Well differentiated (low grade)
G2: Moderately differentiated (intermediate grade)
G3: Poorly differentiated (high grade)
G4: Undifferentiated (high grade)
- TNM code: e,g, T3N0M0, etc
- Stage : Stage I, Stage II, Stage III or Stage IV (with subscript, if applicable)
- Positive lymph nodes: eg., X positive out of Y sampled.
- Mets: Location of remote metastases, if any (e.g., mets to liver, mets to lungs, etc)
- Baseline CEA value (if known)
- Lymphovascular invasion (LVI) (if known): present vs. absent
- Perineural invasion (PNI) (if known): present vs. absent
- Surgical margins (proximal, distal, circumferential): clear or involved
- MSI status (if known): MSI-H, MSS, etc.
- Lynch status (if known)
- KRAS/BRAF status (if known)
- Primary surgery type:
LAR, ULAR, TME, EMR, APR, Laparascopic vs. open resection, polypectomy, proctosigmoidectomy, colectomy, hemi-colectomy, sigmoid-colectomy, etc...
- Ostomy surgery: Ileostomy, or colostomy, or no ileo surgery
- Radiation therapy (if any): Chemo/radiation
- Adjuvant Chemotherapy (if any): e.g., XELOX(CAPEOX), FOLFOX, FOLFIRI, Xeloda monotherapy, 5FU/LV, etc.
- Immunotherapy, targeted therapy (if any)
- Clinical trials (if any)
- - -
ANNOTATED COMMENTS, BY LINE NUMBER
Line #1 - OK
Line #2 - OK
Line #3 - It's not clear exactly where the tumor was and how large it was. You say, "5+cm at dentate line extending to rectal vau" but what does 5+cm mean? Is this the size of the tumor? Is this the distance from the AV? It's not clear. Also, what is the reference to "rectosigmoid junction" all about? Why is this mentioned at all in the report? Is that where the tumor was? Is that where the proximal margin was? Is that where the J-pouch was connected? Was the recto-sigmoid junction removed during surgery? It's all very confusing to me
Line #4 - OK
Line #5 - The size of the tumor is not explicitly mentioned as such. We need to know how large it was, how far down it extended and how far up it reached.
Line #6 - OK
Line #7 - Possibly OK. I would prefer to list the TNM stage as T3N2aM0, provided the T value is truly T3. The issue is with the comment "Deep ulcerated 2.0 cm." in your signature which could suggest that the original tumor (before chemo/rad) might have grown deeper into the rectal wall than T3 level and might have been a more risky T4a tumor, not a T3 tumor. I find the "Deep ulcerated 2.0 cm. " comment very puzzling, and I don't see why it was mentioned in the report without explaining its significance for TNM staging. Also, I would prefer not to use the ypT3N2aM0 type of notation since that is reserved for post-treatment pathology, and what we are really interested in is what the risk-factor profile was before
any treatment was delivered.
Line #8 - OK
Line #9 - OK
Line #10 - Not applicable
Line #11 - The baseline CEA tumor marker blood test should have been done after the colonoscopy and before the start of chemo/radiation. If it was never done, then your DH is without an important baseline.
Line #12 - Since there were 6 involved lymph nodes, then LVI was probably present, otherwise how would those lymph nodes have become infected, However, the chemo/radiation treatment may have obliterated all evidence of LVI in the vascular network, so LVI might not appear explicitly in the post-surgery pathology report. Check with the oncologist about this.
Line #13 - Similar to comment #12 above: The pathologist might not have been able to see any evidence of PNI, since the evidence for PNI might have disappeared due to heavy chemo/radiation effect. Check with the oncologist about this. In any event the pathologist should have put PNI in the report, if only to check the box "Unable to assess". That's what is required in the CAP standard..
Line #14 - You haven't mentioned margins anywhere in your signature. There are three types of margins. Very Important.
Line #15 - MSI status is missing. This is very important and has been a mandatory reporting element for all CRC pathology reports since January 1, 2018. It should be in the report somewhere, but may be under a different name. Check with the oncologist about this. If it is completely missing, then this is a very serious matter. and should be resolved before first-line chemotherapy is started.
Line #16 - Probably not needed right now, unless there is evidence of family history of CRC
Line #17 - Probably not needed right now. Might be needed in special cases.
Line #18 - OK
Line #19 - OK
Line #20 - OK
Line #21 - The type of adjuvant chemotherapy protocol needs to be specifed more accurately, as well as planned start date / stop date.
Line #22 - Not needed right now
Line #23 - Not needed right now