PEDIATRIC SOLID TUMOR REGISTRY
IAPS Registration No. (for office use):
PERSONAL INFORMATION:
Patient's Name:
Age:
Sex:
Date of Birth:
Address:
Telephone No.:
E-mail:
Name of the Institution:
Name of the Surgeon:
Surgeon's Email:
Surgeon's Telephone No.:
CLINICAL DETAILS:
Pain: Yes No Lump: Yes No Fever: Yes No Haematuria: Yes No
Presentation with Metastasis: Yes No Duration of symptoms:
Signs:
Site:
Size (cms):
Palpable Metastasis:
Any other signs:
Provisional Diagnosis:
INVESTIGATIONS:
X-Rays:
USG:
CT-Scan:
MRI:
Bone Marrow:
Bone Scan:
MIBG:
Tumor Markers (LDH)
VMA / HVA
AFP
B-HCG:
Biopsy (FNAC/Trucut/Gun):
Any other investigation:
Surgery (S): Yes No Chemo (C): Yes No Radioth (R): Yes No
Order of (S), (C), (R): 1. Select Surgery (S) Chemo (C) Radioth (R) 2. Select Surgery Chemo Radioth 3. Select Surgery Chemo Radioth
OPERATIVE DETAILS:
Type of Surgery:
Excision:
SCT:
On table complication (esp. Tumor rupture):
Lymph node sampling:
HISTOPATHOLOGY:
FINAL DIAGNOSIS:
STAGE OF TUMOR:
GRADE OF TUMOR:
REGIME OF CHEMOTHERAPY:
REGIME OF RADIOTHERAPY:
OTHER THERAPIES (If any):
TREATMENT FOR METASTASES:
OUTCOME:
Date of last follow-up:
Condition at last follow-up:
(Mark as Yes or No)
Event free survival:
Tumor free survival:
Residual disease:
Complete Resolution:
Cured:
Date of Submission: Monday, January 01, 2007 02:10:28 PM