GLYCOMARKERS IN LUNG CANCER

IDENTIFICATION Date: / / Study number : Hospital number: Patient initials: Date of birth: Sex: Race: BMI: CLINICAL Absence Other No Previous tumors: Organ Organ Organ Present symptoms: Clinical exam: Performance status: Other diseases: Current medication: Previous exams: Thorax CT EBUS/EUS-FNA Tumor location: Tumor size: Endobronchial: TNM classification: Atelectasis/OP: RUL Central 2cm 2-3cm >3-5cm >5-7cm >7cm PET (-CT) Bronchoscopy Mediastinoscopy RML RLL Transthoracic-FNA Other LUL LLL ECOG 0 1 2 3 4 Cough Chest pain Yes Diagnosis date Diagnosis date Diagnosis date Dyspnea Anorexia Treatments Treatments Treatments Sputum Weigh loss Hemoptysis Other: packs-year smoking cessation (yrs) Patient registration

Physician initials: Check-list: Anamnesis + clinical exam Peripheral venous blood sample Lung cancer tissue Normal lung tissue

Risk factors:

Without lobar invasion Carina invasion Absence Visceral pleura

Main bronchus 2cm distal to carina Main bronchus <2cm distal to carina Lobar Entire lung

Local invasion:

Chest wall / diaphragm / mediastinal pleura / parietal pericardium / phrenic Mediastinum / trachea / heart / great vessels / esophagus / vertebra

Separate nodules: Lymph nodes:

Within the same lobe 2 L / R 7 3 8

Ipsilateral lung but different lobe 4 L / R 9 5 10 L / R 6 11 L / R

Metastasis: Clinical staging: Definitive diagnosis: Blood tumor markers: Previous treatment: T No Cyfra 21 Absence Yes

Pleural/pericardial effusion Other organs: N Obtained how? CEA NSE Chemotherapy M

Contralateral lung tumor nodule(s)

Stage Histological type:

Radiotherapy

TECHNICAL PROCEDURE Surgery type: Specimen type: Specimen location: Complications: VATS Single wedge resection Lobectomy/bilobectomy Right lung No Tumor Collected specimens: Normal lung tissue Venous blood sample VATS converted to open Multiple wedge resections Pneumonectomy Left lung Yes: Lobe: Lobe: Time: PATHOLOGY REPORT Main bronchus within 20 mm of carina (T3) (if known) Main bronchus more than 20 mm from carina (T2) Macroscopic features: Location of the tumor: Tumor size (maximum dimension): mm mm Time: Time: Rotulation: Rotulation: Rotulation: Open Segmentectomy Sleeve resection

Distance of tumor from bronchial resection margin: Extent of atelectasis / obstructive pneumonia: Squamous cell carcinoma Small cell lung cancer Subtype: Local invasion: Microscopic features: Satellite nodules: Lymph node spread N1: Lymph node spread N2: Lymph node spread N3: Margins: Metastasis: Pathological staging: pT pN Unknown pM CLINICAL FOLLOW-UP Observation Chemotherapy: 1 month: Follow-up: 3 months: 6 months: 1 year: 2 years: 5 years: Remarks: Radiotherapy No No Submitted Submitted Submitted Adenocarcinoma Other:

Large cell carcinoma

Yes: Yes: Involved Involved Involved Involved Absent Clear Clear Clear Clear Present M1a Stage M1b

Proposed treatment:

Surgery

Other: