Pathology Form (Form 24-P) Brain Function in Premenopausal Women Receiving Tamoxifen With or Without Ovarian Function Suppression for Early-Stage Breast Cancer on Clinical Trial IBCSG-2402 Source Form: NCI FormBuilder:


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January 9, 2015

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Breast Cancer NCT00659373 Pathology - Pathology Form (Form 24-P) - 2074955v3.0

PATHOLOGY FORM (Form 24-P) Instructions: This form is to be completed by participating pathologist or investigator. Submit this form within 1 month of randomization, with the pathology report(s) and required pathology materials. Mark your selection with an ?X? in the appropriate box(es). Use minus one (-1) to indicate that an answer is unknown, unobtainable or not done.

Ccrr Module For Pathology Form (form 24-p)
This form is being completed for
Primary Tumor
Histological type (Dominant)
Differentiation (select one)
Excision Margins
Invasive cancer
Vessel Invasion
Was there invasion of vessels around primary tumor? (select one)
Score by immunohistochemistry
Immunohistochemistry Kit or Test Type
Type of Assay
Her2/neu status, (by other technique)
Nodal Involvement
Extracapsular Extension
Isolated tumor cells only
Largest tumor deposit
Largest tumor deposit
Form completed by (select one)

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