Supplementary Endoscopy Report Form Colorectal Cancer Screening In Patients Treated With Radiation Therapy COLONOSCOPY FORM and PATHOLOGY REPORT Completed by:____________ Date: _____/_____/_____ MRN#: ________________________ Mo Day Year Participant Initials: ___________ Study Id No: ____________________ 1. Record the size, location, type of polyp, and procedures for removal of each polyp. Indicate location of polyp(s) on diagram below using assigned polyp letters. **Note: Assess size using open biopsy forcep** Location Shape Procedure Histology Atypia/Dysplasia CE = Cecum P = Peunculated 1 = Snare polypectomy C = Carcinoma H = High Grade Dysplasia AC = Ascending Colon S = Sessile 2 = Hot biopsy forceps N = Normal L = Low Grade Dysplasia HF = Hepatic Flexure U = Unable to be 3 = Cold biopsy H = Hyperplastic U = Unable to be TC = Transverse Colon determined, not 4 = Not removed T = Tubular determined, not mentioned SF = Splenic Flexure mentioned 5 = Lost/insufficient V = Villous N = None DC = Descending Colon M = Mixed Tubulovillous SC = Sigmoid Colon A = Adenomatous, not specified RE = Rectum U = Unable to be determined, not mentioned O = Other: ________________________________ Polyp Location Distance (cm) Diameter Shape Procedure Histology Atypia Letters from anal verge (mm) A _______ ___________ _______ _______ _______ _______ _______ B _______ ___________ _______ _______ _______ _______ _______ C _______ ___________ _______ _______ _______ _______ _______ D _______ ___________ _______ _______ _______ _______ _______ E _______ ___________ _______ _______ _______ _______ _______ F _______ ___________ _______ _______ _______ _______ _______ G _______ ___________ _______ _______ _______ _______ _______ H _______ ___________ _______ _______ _______ _______ _______ I _______ ___________ _______ _______ _______ _______ _______ J _______ ___________ _______ _______ _______ _______ _______ 1 Supplementary Endoscopy Report Form Colorectal Cancer Screening In Patients Treated With Radiation Therapy COLONOSCOPY FORM and PATHOLOGY REPORT Completed by:____________ Date: _____/_____/_____ MRN#: ________________________ Mo Day Year Participant Initials: ___________ Study Id No: ____________________ Code: 1 = Yes 2 = No 2. Other Results Found During the Procedure ….……………………………..……._____ If Yes: a) Hemorrhoids …………………………….………………………….…………_____ b) Diverticula ……………………………….………………………….……….. _____ c) Chronic inflammation…………………….…………………………………..._____ d) Other, please specify: ___________________________________________ 3. Presence of polyp(s) in distal 60 cm (1 = Yes, 2 = No) ……………..……………_____ 4. Farthest extent reached is: a) If ≤60 cm, farthest extent visualized (cm)..………………….……….……..…_____ If > 60 cm, farthest extent visualized by location: b) Splenic Flexure……………………………………………………….…….…._____ c) Transverse Colon…………………………………………………………..….._____ d) Hepatic Flexure……………………………………….………………………._____ e) Ascending Colon………….…………………………………………………..._____ f) Cecum …..………..……………………………………………………………_____ 2 Supplementary Endoscopy Report Form Colorectal Cancer Screening In Patients Treated With Radiation Therapy COLONOSCOPY FORM and PATHOLOGY REPORT Completed by:____________ Date: _____/_____/_____ MRN#: ________________________ Mo Day Year Participant Initials: ___________ Study Id No: ____________________ Code: 1 = Yes 2 = No 5. Pathology Results a) Lipoma………………………………………………………………………. _____ b) Inflammatory polyp………………………………………………………….._____ c) Juvenile polyp………………………………………………………………..._____ d) Carcinoid tumor…………………………………………………………..……_____ e) Carcinoma……………………………………………………………….……._____ f) Lymphoid hyperplasia………………………………………………..……….._____ g) Other, please specify: _________________________________________________ 6. Presence of adenomatous polyp(s) or cancer (1 = Yes, 2 = No) …………………._____ 7. Total number of adenomatous polyps………………………………………..……_____ 8. Presence of adenomatous polyp(s) or cancer in distal 60 cm (1 = Yes, 2 = No) …_____ Colonoscopist: _______________________________ (Please Print Name) Colonoscopist Signature: _______________________________ P.I. Signature: ______________________________ 3 .