NSABP PROTOCOL R-04: SURGERY FORM Radiation Therapy and Either Capecitabine or Fluorouracil With or Without Oxaliplatin Before Surgery in Treating Patients With Resectable Rectal Cancer Source Form: NCI FormBuilder:

  1. 8/27/12 8/27/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
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January 9, 2015

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Creative Commons BY-NC 3.0 Legacy
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Colorectal Cancer NCT00058474 Treatment - NSABP PROTOCOL R-04: SURGERY FORM - 2086952v3.0

(If a resection was not performed, submit supporting documentation and leave the remainder of the form blank.)

Ccrr Module For Nsabp Protocol R-04: Surgery Form
Are data amended
Perioperative Tumor Assessment Of Clinical Response
Clinical response
Clinical response
Vascular Access Device
Blood Transfusions
Blood transfusion
Did patient undergo surgical resection?
Reason for no resection
Found on
Is there adherence to adjacent organs?
Was an "en bloc" resection performed?
Residual Primary Tumor
Was an abdominal exploration carried out?
Was there tumor spillage?
Was sphincter preserved
Was a total mesorectal excision performed?
Were all suspicious lymph nodes removed?
Were there any isolated distant or non-contiguous intra-abdominal mets (other than peri-rectal lymph node involvement)?
Metastasis completely resected
Was there bowel perforation
Indicate the type (perforation)
Was there bowel obstruction
Indicate the type (tumor)
Was an ostomy created at the time of resection?
Location of distal edge of tumor
Were there any Post-operative and Early Complications
Mark all that apply
Wound infection, mark type
Urinary complication, choose type
Was a re-operation necessary?
Pathologic T Stage
Pathologic response
Histologic Type (mark one)
Venous Invasion
Histologic Grade (Differentiation)
All surgical margins of resection are negative for tumor
Which margin was involved?

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