ID

1660

Descripción

Gynecologic Oncology Group Surgical Reporting Form (Form C) Bevacizumab and Intravenous or Intraperitoneal Chemotherapy in Treating Patients With Stage II, Stage III, or Stage IV Ovarian Epithelial Cancer, Fallopian Tube Cancer, or Primary Peritoneal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=4F53ABD3-7FB6-64F0-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=4F53ABD3-7FB6-64F0-E044-0003BA3F9857

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Subido en

19 de septiembre de 2012

DOI

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Licencia

Creative Commons BY-NC 3.0 Legacy

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Fallopian Tube Cancer NCT00951496 Treatment - Gynecologic Oncology Group Surgical Reporting Form (Form C) - 2758023v1.0

model
Detalles

No Instruction available.

1 formularios

StudyEvent: Gynecologic Oncology Group Surgical Reporting Form (Form C)
1. No Instruction available.

Name

Tipo

Description | Question | Decode (Coded Value)

Tipo de datos

Alias

HEADER MODULE

Item Group

Header Module

FormOriginalCompleteDate

Item

Date form originally completed (m d y)

date

C19464 (NCI Thesaurus ObjectClass)
C0376315 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25604 (NCI Thesaurus Property)
C0205313 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain)

FormAmendedCompleteDate

Item

Date form amended (m d y)

date

C19464 (NCI Thesaurus ObjectClass)
C0376315 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain)

ResponsiblePersonReportingChangeLastName

Item

Person amending form, last name

text

C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)

PatientInitialsName

Item

Patient Initials (First, Middle, Last)

text

C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)

PatientGynecologicOncologyGroupIdentifierNumber

Item

Patient Study ID

text

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25521 (NCI Thesaurus Property)
C1512288 (UMLS 2011AA Property)

ResponsiblePersonLastName

Item

Person completing form, last name

text

C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25657 (NCI Thesaurus ObjectClass)
C1273518 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25551 (NCI Thesaurus Property)
C1517741 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)

Unnamed1

Item Group

Unnamed1

GynecologicSurgicalProcedurePerformedType

Item

Operative procedure performed (check all that apply)

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C28016 (NCI Thesaurus ObjectClass)
C0205480 (UMLS 2011AA ObjectClass)

CL.1

Code List

Operative procedure performed (check all that apply)

CL Item

Bilateral Salpingo-oophorectomy (bilateral salpingo-oophorectomy)

CL Item

Deep Lymphadenectomy (Deep lymphadenectomy)

CL Item

Exenteration (Exenteration)

CL Item

Hemivolvectomy (Hemi volvectomy)

CL Item

Interval Debulking (Interval debulking)

CL Item

Omentectomy (omentectomy)

C0198614 (NCI Metathesaurus)

CL Item

Other, Specify (other specify)

CL Item

Para-aortic Node Sampling/dissection (para-aortic node sampling/dissection)

CL Item

Pelvic Node Sampling/dissection (pelvic node sampling/dissection)

CL Item

Primary Debulking (Primary debulking)

CL Item

Radical Hysterectomy (radical hysterectomy)

CL Item

Radical Trachelectomy (radical trachelectomy)

CL Item

Radical Vulvectomy (Radical vulvectomy)

CL Item

Reassessment Laparotomy (Reassessment laparotomy)

CL Item

Superficial Lymphadenectomy (Superficial lymphadenectomy)

CL Item

Total Abdominal Hysterectomy (Total abdominal hysterectomy)

CL Item

Total Vaginal Hysterectomy (Total vaginal hysterectomy)

CL Item

Unilateral Salpingo-oophorectomy (unilateral salpingo-oophorectomy)

C28012 (NCI Thesaurus)
C0205092 (UMLS 2011AA)
C15323 (NCI Thesaurus)
C0036132 (UMLS 2011AA)

GynecologicSurgicalProcedurePerformedSpecify

Item

Other, specify

text

C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C28016 (NCI Thesaurus ObjectClass)
C0205480 (UMLS 2011AA ObjectClass)

SurgicalProcedureApproachType

Item

Surgical approach

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C25424 (NCI Thesaurus Property)
C0449445 (UMLS 2011AA Property)

CL.2

Code List

Surgical approach

CL Item

Open (open)

CL Item

Laparoscopic Surgery (Laparoscopic)

C15725 (NCI Thesaurus)
C0751429 (UMLS 2011AA)

GynecologicTumorGroupingStage

Item

Stage

text

C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C28016 (NCI Thesaurus ObjectClass)
C0205480 (UMLS 2011AA ObjectClass)
C16899 (NCI Thesaurus ValueDomain)
C1300072 (UMLS 2011AA ValueDomain)
C25523 (NCI Thesaurus Property)
C1522242 (UMLS 2011AA Property)

CL.3

Code List

Stage

CL Item

0 (0)

C0919414 (NCI Metathesaurus)

CL Item

Refer To Figo Staging For Specific Gynecologic Cancer (1)

CL Item

Refer To Figo Staging For Specific Gynecologic Cancer (1A)

CL Item

Refer To Figo Staging For Specific Gynecologic Cancer (1B)

CL Item

Refer To Figo Staging For Specific Gynecologic Cancer (1C)

CL Item

Refer To Figo Staging For Specific Gynecologic Cancer (2)

CL Item

Refer To Figo Staging For Specific Gynecologic Cancer (2A)

CL Item

Refer To Figo Staging For Specific Gynecologic Cancer (2B)

CL Item

Refer To Figo Staging For Specific Gynecologic Cancer (2C)

CL Item

Refer To Figo Staging For Specific Gynecologic Cancer (3)

CL Item

Refer To Figo Staging For Specific Gynecologic Cancer (3A)

CL Item

Refer To Figo Staging For Specific Gynecologic Cancer (3B)

CL Item

Refer To Figo Staging For Specific Gynecologic Cancer (3C)

CL Item

Refer To Figo Staging For Specific Gynecologic Cancer (4)

CL Item

Refer To Figo Staging For Specific Gynecologic Cancer (4A)

CL Item

Refer To Figo Staging For Specific Gynecologic Cancer (4B)

CL Item

Persistent (Persistent)

CL Item

Recurrent (Recurrent)

C14173 (NCI Thesaurus)
C2945760 (UMLS 2011AA)

CL Item

Not Available (Not available)

Unnamed2

Item Group

Unnamed2

SurgeryDate

Item

Surgery Date (m d y)

date

C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain)
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)

TumorPercentageRemovedAmount

Item

Percent of gross tumor removed (%)

double

C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C25417 (NCI Thesaurus ValueDomain)
C25650 (NCI Thesaurus Property)
C0849355 (UMLS 2011AA Property)

GrossTumorResidualRemainingInd-2

Item

Residual gross tumor

text

C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C43566 (NCI Thesaurus ObjectClass)
C0439806 (UMLS 2011AA ObjectClass)
C37895 (NCI Thesaurus Property)
C1609982 (UMLS 2011AA Property)
C25649 (NCI Thesaurus Property)
C1527428 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)

CL.4

Code List

Residual gross tumor

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

CL Item

No (No)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

Unnamed3

Item Group

Unnamed3

LargestMalignantNeoplasmLongestDiameterMeasurement

Item

Greatest diameter of largest residual gross tumor mass

double

C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
C25550 (NCI Thesaurus ObjectClass)
C0443228 (UMLS 2011AA ObjectClass)
C25285 (NCI Thesaurus Property)
C1301886 (UMLS 2011AA Property)
C25558 (NCI Thesaurus Property)
C1522425 (UMLS 2011AA Property)
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)

MicroscopicDiseasePresentInd-2

Item

Microscopic disease only

text

C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)

CL.5

Code List

Microscopic disease only

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

CL Item

No (No)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

AscitesPresentInd-3

Item

Ascites

text

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C2885 (NCI Thesaurus ObjectClass)
C0003962 (UMLS 2011AA ObjectClass)

CL.6

Code List

Ascites

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

CL Item

No (No)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

FluidCytologyResultType

Item

Cytology of peritoneal or ascitic fluids

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C16491 (NCI Thesaurus ObjectClass)
C0010819 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)

CL.7

Code List

Cytology of peritoneal or ascitic fluids

CL Item

Positive (Positive)

C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)

CL Item

Suspicious (Suspicious)

C0750493 (NCI Metathesaurus)

CL Item

Negative (Negative)

C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)

CL Item

Not Done (Not done)

CL281691 (NCI Metathesaurus)

CL Item

Unavailable (Unavailable)

Unnamed4

Item Group

Unnamed4

GynecologicInvolvedSiteName

Item

Summary of operative findings (*)

text

C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C28016 (NCI Thesaurus ObjectClass)
C0205480 (UMLS 2011AA ObjectClass)

CL.8

Code List

Summary of operative findings (*)

CL Item

Uterus-corpus (Uterus-corpus)

CL Item

Uterus-cervix (Uterus-cervix)

CL Item

Vagina (Vagina)

C12407 (NCI Thesaurus)
C0042232 (UMLS 2011AA)

CL Item

Fallopian Tube - Rt. (Fallopian tube - rt.)

CL Item

Fallopian Tube - Lt. (Fallopian tube - lt.)

CL Item

Ovary - Rt. (Ovary - rt.)

CL Item

Ovary - Lt. (Ovary - lt.)

CL Item

Bladder - Mucosa (Bladder - mucosa)

CL Item

Bladder - Muscularis (Bladder - muscularis)

CL Item

Ureter - Rt. (Ureter - rt.)

CL Item

Ureter - Lt. (Ureter - lt.)

CL Item

Parametrium - Rt. (Parametrium - rt.)

CL Item

Parametrium - Lt. (Parametrium - lt.)

CL Item

Labium Major - Rt. (Labium major - rt.)

CL Item

Labium Major - Lt. (Labium major - lt.)

CL Item

Labium Minor - Rt. (Labium minor - rt.)

CL Item

Labium Minor - Lt. (Labium minor - lt.)

CL Item

Clitoris (Clitoris)

CL Item

Urethra (Urethra)

CL Item

Introitus (Introitus)

CL Item

Perineal Body (Perineal body)

CL Item

Anus (Anus)

C43362 (NCI Thesaurus)
C0003461 (UMLS 2011AA)

CL Item

Pelvic - Rt. (Pelvic - rt.)

CL Item

Pelvic - Lt. (Pelvic - lt.)

CL Item

Pelvic Bladder (Pelvic bladder)

CL Item

Pelvic Cul-de-sac (Pelvic cul-de-sac)

CL Item

Ant. Abdomen (Ant. Abdomen)

CL Item

Gutters - Rt. (Gutters - rt.)

CL Item

Gutters - Lt. (Gutters - lt.)

CL Item

Subdiaphragm - Rt. (subdiaphragm - rt.)

CL Item

Subdiaphragm - Lt. (subdiaphragm - lt.)

CL Item

Stomach (Stomach)

C12391 (NCI Thesaurus)
C0038351 (UMLS 2011AA)

CL Item

Duodenum (Duodenum)

C12263 (NCI Thesaurus)
C0013303 (UMLS 2011AA)

CL Item

Jejunum (Jejunum)

C12388 (NCI Thesaurus)
C0022378 (UMLS 2011AA)

CL Item

Ileum (Ileum)

CL Item

Appendix (Appendix)

C12380 (NCI Thesaurus)
C0003617 (UMLS 2011AA)

CL Item

Ascending Colon (Ascending colon)

C12265 (NCI Thesaurus)
C0227375 (UMLS 2011AA)

CL Item

Transverse Colon (Transverse colon)

C12385 (NCI Thesaurus)
C0227386 (UMLS 2011AA)

CL Item

Descending Colon (Descending colon)

C12268 (NCI Thesaurus)
C0227389 (UMLS 2011AA)

CL Item

Sig. Mucosa (Sig. Mucosa)

CL Item

Sig. Muscularis (Sig. Muscularis)

CL Item

Small Bowel (Small bowel)

CL Item

Large Bowel (Large bowel)

CL Item

Liver Surface (Liver surface)

CL Item

Liver Parenchyma (Liver parenchyma)

CL Item

Spleen (Spleen)

C12432 (NCI Thesaurus)
C0037993 (UMLS 2011AA)

CL Item

Gall Bladder (Gall bladder)

CL Item

Pancreas (Pancreas)

C12393 (NCI Thesaurus)
C0030274 (UMLS 2011AA)

CL Item

Kidney - Rt. (Kidney - rt.)

CL Item

Kidney - Lt. (Kidney - lt.)

CL Item

Adb. Ureter - Rt. (Adb. Ureter - rt.)

CL Item

Adb. Ureter - Lt. (Adb. Ureter - lt.)

CL Item

Omentum - Gastrocolic (Omentum - gastrocolic)

CL Item

Omentum - Infracolic (Omentum - infracolic)

CL Item

Left Scalene (Left scalene)

CL Item

Para-aortic - Rt. (Para-aortic - rt.)

CL Item

Para-aortic - Lt. (Para-aortic - lt.)

CL Item

Common Iliac - Rt. (Common iliac - rt.)

CL Item

Common Iliac - Lt. (Common iliac - lt.)

CL Item

External Iliac - Rt. (External iliac - rt.)

CL Item

External Iliac - Lt. (External iliac - lt.)

CL Item

Obturator - Rt. (Obturator - rt.)

CL Item

Obturator - Lt. (Obturator - lt.)

CL Item

Internal - Rt. (Internal - rt.)

CL Item

Internal - Lt. (Internal - lt.)

CL Item

Superficial Gr. - Rt. (Superficial gr. - rt.)

CL Item

Superficial Gr. - Lt. (Superficial gr. - lt.)

CL Item

Deep Groin - Rt. (Deep groin - rt.)

CL Item

Deep Groin - Lt. (Deep groin - lt.)

GynecologicExaminedSite

Item

Exam (*Examined: 1=tumor present; 2=no tumor; 3=suspicious; 4=organ absent; 5=not examined)

text

C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)
C25500 (NCI Thesaurus Property)
C0332128 (UMLS 2011AA Property)
C28016 (NCI Thesaurus ObjectClass)
C0205480 (UMLS 2011AA ObjectClass)

CL.9

Code List

Exam (*Examined: 1=tumor present; 2=no tumor; 3=suspicious; 4=organ absent; 5=not examined)

CL Item

Tumor Present (Tumor present)

CL Item

No Tumor (No tumor)

CL Item

Suspicious (Suspicious)

C0750493 (NCI Metathesaurus)

CL Item

Organ Absent (Organ absent)

CL Item

Not Examined (Not examined)

GynecologicProcedureSite

Item

Proc (*Procedure: 1=removed partially; 2=removed completely; 3=biopsy only; 4=left intact; 5=not applicable)

text

C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)
C15368 (NCI Thesaurus Property)
C28016 (NCI Thesaurus ObjectClass)
C0205480 (UMLS 2011AA ObjectClass)

CL.10

Code List

Proc (*Procedure: 1=removed partially; 2=removed completely; 3=biopsy only; 4=left intact; 5=not applicable)

CL Item

Removed Partially (Removed partially)

CL Item

Removed Completely (Removed completely)

CL Item

Biopsy Only (Biopsy only)

CL Item

Left Intact (Left intact)

CL Item

Not Applicable (Not applicable)

C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)

Comments

Item Group

Comments

ResearchCommentsText

Item

Comments

text

C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0282411 (UMLS 2011AA Property)

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Palabras clave

Versiones (3)

Subido en

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Licencia

Comentarios del modelo :

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Fallopian Tube Cancer NCT00951496 Treatment - Gynecologic Oncology Group Surgical Reporting Form (Form C) - 2758023v1.0

No Instruction available.

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