Clinical Trials Pathology Assessment
Complete this form to document and evaluate pathology findings for clinical trial specimens.
Patient Full Name
*
First Name
Last Name
Patient Study ID
*
Specimen ID
*
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Pathologist Name
*
First Name
Last Name
Type of Specimen
*
Please Select
Biopsy
Surgical Resection
Blood Sample
Other
Histological Grade
*
Grade 1 (Well differentiated)
Grade 2 (Moderately differentiated)
Grade 3 (Poorly differentiated)
Not applicable
Tumor Characteristics Assessment
*
Rows
Absent
Focal
Diffuse
Necrosis
1
2
3
Inflammation
4
5
6
Fibrosis
7
8
9
Vascular Invasion
10
11
12
Percentage of Tumor Cells Present
*
Immunohistochemistry Marker Positivity
Marker A (Positive)
Marker B (Positive)
Marker C (Positive)
No positive markers
Other
Overall Pathology Assessment
*
1
2
3
4
5
Additional Comments / Observations
Pathologist Signature
*
Submit Assessment
Submit Assessment
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