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Sample, Sammy G
ST0001
Biopsy Form
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If a new lesion is identified at a later point and new diagnostics are performed, please use a new form.
Biopsy
Was a biopsy performed?
No
Yes
Procedure date
MM/DD/YYYY
Where was the biopsy performed?
Indication for biopsy
Size
No resolution after abx
Growth
Positive PET
Other (specify)
Lesion site
LUL
LLL
L hilum
L lingula
RUL
RML
RLL
R hilum
Endobronchial
Mediastinum
Pleura
Other (specify)
Type of specimen
Cytology
Histology
Type of procedure
Needle biopsy
Bronchoscopy
VAT
Thoracotomy
Other (specify)
Complications during biopsy?
No
Yes
Type of complication
Chest tube
Pneumothorax
Pneumonectasis
Other (specify)
Biopsy pathology details
Mediastinoscopy
Was a mediastinoscopy performed?
No
Yes
Procedure date
MM/DD/YYYY
Where was the mediastinoscopy performed?
Lesion site
LUL
LLL
L hilum
L lingula
RUL
RML
RLL
R hilum
Endobronchial
Mediastinum
Pleura
Other (specify)
Complications during procedure?
No
Yes
Specify
Molecular Testing
Was molecular testing performed on the pathology specimen?
No
Yes
EGFR
No
Negative
Positive
K-Ras
No
Negative
Positive
ALK
No
Negative
Positive
Other
No
Negative
Positive
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