ID

10350

Beschreibung

Radiation Therapy Oncology Group Phase III Lung Prophylactic Cranial RT Radiotherapy Summary Form Radiation Therapy in Preventing CNS Metastases in Patients With Non-Small Cell Lung Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9EC372A6-73DB-05D5-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9EC372A6-73DB-05D5-E034-080020C9C0E0

Stichworte

  1. 19.09.12 19.09.12 -
  2. 28.05.15 28.05.15 -
  3. 03.06.15 03.06.15 -
Hochgeladen am

28. Mai 2015

DOI

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Creative Commons BY-NC 3.0 Legacy

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Radiation Therapy Oncology Group Phase III Lung Prophylactic Cranial RT Radiotherapy Summary Form

No Instruction available.

  1. StudyEvent: Radiation Therapy Oncology Group Phase III Lung Prophylactic Cranial RT Radiotherapy Summary Form
    1. No Instruction available.
Header Module
Beschreibung

Header Module

Institution
Beschreibung

InstitutionName

Datentyp

text

Institution #
Beschreibung

NCIInstitutionNumber

Datentyp

text

Patient Name
Beschreibung

PatientName

Datentyp

text

Case #
Beschreibung

Case#

Datentyp

text

Patient ID #
Beschreibung

PatientID#

Datentyp

text

RADIOTHERAPY documentation
Beschreibung

RADIOTHERAPY documentation

If this is a revised or corrected form, indicate by checking box.
Beschreibung

AmendedDataInd

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
FIRST DATE PROTOCOL THERAPY WAS GIVEN
Beschreibung

TreatmentBeginDate

Datentyp

date

LAST DATE PROTOCOL THERAPY WAS GIVEN
Beschreibung

ProtocolTreatmentAdministeredEndDate

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass
C42651
UMLS 2011AA ObjectClass
C0442711
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Primary Tumor Site, DOSE SUMMARY (Complete for all treatment fields or as specified within the protocol. Specify fractions and dose for each volume a-d, record totals in e. Fractions Dose Gy)
Beschreibung

PrimaryTumorSite,DOSESUMMARY

Datentyp

text

Dose (Gy)
Beschreibung

Dose(Gy)

Datentyp

text

Total to Primary Site
Beschreibung

RTTotalFractionCount

Datentyp

double

Regional Nodes, Dose Summary
Beschreibung

Local-RegionalLymphNodeRadiationTherapyAdministeredDose

Datentyp

double

Alias
NCI Thesaurus ObjectClass
C15313
UMLS 2011AA ObjectClass
C1522449
NCI Thesaurus ObjectClass
C12745
UMLS 2011AA ObjectClass
C0024204
NCI Thesaurus ObjectClass
C25388
UMLS 2011AA ObjectClass
C1947913
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
NCI Thesaurus ValueDomain
C25488
UMLS 2011AA ValueDomain
C0178602
Fractions
Beschreibung

Fractions

Datentyp

text

Fractions
Beschreibung

Fractions

Datentyp

text

Dose (Gy)
Beschreibung

Dose(Gy)

Datentyp

text

Nodal Sites
Beschreibung

LymphNodesType

Datentyp

text

Other volume, specify
Beschreibung

Othervolume,specify

Datentyp

text

Critical Structures
Beschreibung

RadiationTherapyCriticalAnatomicSite

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C15313
UMLS 2011AA ObjectClass
C1522449
NCI Thesaurus Property
C25341
UMLS 2011AA Property
C0450429
NCI Thesaurus Property
C25421
UMLS 2011AA Property
C0002808
NCI Thesaurus Property
C25467
UMLS 2011AA Property
C1511545
NCI Thesaurus ValueDomain
C13717
UMLS 2011AA ValueDomain
C1515974
Maximum Dose (Gy)
Beschreibung

RTMaximumDose,CriticalStructures

Datentyp

double

WERE THERE ANY DOSE MODIFICATIONS OR ADDITIONS/OMISSIONS TO PROTOCOL TREATMENT? (Must be completed for all patients assigned radiotherapy.)
Beschreibung

DoseModification(Change)

Datentyp

text

Were there any dose modifications or additions/omissions to protocol treatment other reason, specify (TREATMENT MODIFIED)
Beschreibung

Werethereanydosemodificationsoradditions/omissionstoprotocoltreatmentotherreason,specify

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Split Course Interruption (Complete only if assigned split course. Total number of days interrupted for split between first and second course.)
Beschreibung

SplitCourseInterruption

Datentyp

text

Signature of Person Completing This Form
Beschreibung

SignatureofPersonCompletingThisForm

Datentyp

text

Date
Beschreibung

FormCompletionDate,Original

Datentyp

date

Total # of treatment days RT interrupted for toxicity.
Beschreibung

Total#oftreatmentdaysRTinterruptedfortoxicity.

Datentyp

text

Total # of treatment days RT interrupted for other reasons, specify
Beschreibung

Total#oftreatmentdaysRTinterruptedforotherreasons,specify

Datentyp

text

Total # of treatment days RT interrupted for other reasons, specify
Beschreibung

Total#oftreatmentdaysRTinterruptedforotherreasons,specify

Datentyp

text

Ähnliche Modelle

No Instruction available.

  1. StudyEvent: Radiation Therapy Oncology Group Phase III Lung Prophylactic Cranial RT Radiotherapy Summary Form
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Header Module
InstitutionName
Item
Institution
text
NCIInstitutionNumber
Item
Institution #
text
PatientName
Item
Patient Name
text
Case#
Item
Case #
text
PatientID#
Item
Patient ID #
text
Item Group
RADIOTHERAPY documentation
AmendedDataInd
Item
If this is a revised or corrected form, indicate by checking box.
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
TreatmentBeginDate
Item
FIRST DATE PROTOCOL THERAPY WAS GIVEN
date
ProtocolTreatmentAdministeredEndDate
Item
LAST DATE PROTOCOL THERAPY WAS GIVEN
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C15368 (NCI Thesaurus ObjectClass)
C42651 (NCI Thesaurus ObjectClass)
C0442711 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
PrimaryTumorSite,DOSESUMMARY
Item
Primary Tumor Site, DOSE SUMMARY (Complete for all treatment fields or as specified within the protocol. Specify fractions and dose for each volume a-d, record totals in e. Fractions Dose Gy)
text
Dose(Gy)
Item
Dose (Gy)
text
RTTotalFractionCount
Item
Total to Primary Site
double
Local-RegionalLymphNodeRadiationTherapyAdministeredDose
Item
Regional Nodes, Dose Summary
double
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C12745 (NCI Thesaurus ObjectClass)
C0024204 (UMLS 2011AA ObjectClass)
C25388 (NCI Thesaurus ObjectClass)
C1947913 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C25488 (NCI Thesaurus ValueDomain)
C0178602 (UMLS 2011AA ValueDomain)
Fractions
Item
Fractions
text
Fractions
Item
Fractions
text
Dose(Gy)
Item
Dose (Gy)
text
Item
Nodal Sites
text
Code List
Nodal Sites
CL Item
Head & Neck: Ant to cord (Head & Neck: Ant to cord)
CL Item
Head & Neck: Post to cord (Head & Neck: Post to cord)
CL Item
Head & Neck: Supraclavicular (Head & Neck: Supraclavicular)
CL Item
Lung (Upper/Mid Lobes): Ipsilateral hilar/subcarinal (Lung (Upper/Mid Lobes): Ipsilateral hilar/subcarinal)
CL Item
Lung (Upper/Mid Lobes): Contralateral hilar (Lung (Upper/Mid Lobes): Contralateral hilar)
CL Item
Lung (Upper/Mid Lobes): Supraclavicular (Lung (Upper/Mid Lobes): Supraclavicular)
CL Item
Lung (Lower Lobes): Ipsilateral hilar/subcarinal (Lung (Lower Lobes): Ipsilateral hilar/subcarinal)
CL Item
Lung (Lower Lobes): Contralateral hilar (Lung (Lower Lobes): Contralateral hilar)
CL Item
Lung (Lower Lobes): Inferior mediastinal (Lung (Lower Lobes): Inferior mediastinal)
CL Item
Esophagus: Mediastinal (Esophagus: Mediastinal)
CL Item
Esophagus: Supraclavicular (Esophagus: Supraclavicular)
CL Item
Pelvic/Abdomen Primaries: Int/Ext. Iliac (Pelvic/Abdomen Primaries: Int/Ext. Iliac)
CL Item
Pelvic/Abdomen Primaries: Common Iliac (Pelvic/Abdomen Primaries: Common Iliac)
CL Item
Pelvic/Abdomen Primaries: Para-aortic (Pelvic/Abdomen Primaries: Para-aortic)
CL Item
Pelvic/Abdomen Primaries: Mesenteric (Pelvic/Abdomen Primaries: Mesenteric)
CL Item
Breast: Internal mammary (Breast: Internal mammary)
CL Item
Breast: Axillary (Breast: Axillary)
CL Item
Breast: Supraclavicular (Breast: Supraclavicular)
CL Item
Breast: Other site (Breast: Other site)
Othervolume,specify
Item
Other volume, specify
text
Item
Critical Structures
text
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C25421 (NCI Thesaurus Property)
C0002808 (UMLS 2011AA Property)
C25467 (NCI Thesaurus Property)
C1511545 (UMLS 2011AA Property)
C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)
Code List
Critical Structures
CL Item
Spinal Cord (Spinal cord)
C12464 (NCI Thesaurus)
C0037925 (UMLS 2011AA)
CL Item
Heart (Heart)
C12727 (NCI Thesaurus)
C0018787 (UMLS 2011AA)
CL Item
Contralateral Ni Lung (Contralateral NI lung)
CL Item
Small Bowel (Small bowel)
CL Item
Rectum (Rectum)
C12390 (NCI Thesaurus)
C0034896 (UMLS 2011AA)
CL Item
Large Bowel (excludes Rectum) (Large bowel (excludes rectum))
CL Item
Bladder >50% (Bladder >50%)
CL Item
Liver (Liver)
C12392 (NCI Thesaurus)
C0023884 (UMLS 2011AA)
CL Item
Kidney (Kidney)
C12415 (NCI Thesaurus)
C0022646 (UMLS 2011AA)
CL Item
Lens (rt) (Lens (RT))
CL Item
Lens (lt) (Lens (LT))
CL Item
Esophagus (Esophagus)
C12389 (NCI Thesaurus)
C0014876 (UMLS 2011AA)
CL Item
Other, Specify (Other, specify)
CL Item
Other, specify (Other, specify)
RTMaximumDose,CriticalStructures
Item
Maximum Dose (Gy)
double
Item
WERE THERE ANY DOSE MODIFICATIONS OR ADDITIONS/OMISSIONS TO PROTOCOL TREATMENT? (Must be completed for all patients assigned radiotherapy.)
text
Code List
WERE THERE ANY DOSE MODIFICATIONS OR ADDITIONS/OMISSIONS TO PROTOCOL TREATMENT? (Must be completed for all patients assigned radiotherapy.)
CL Item
NA - XRT dose administered within protocol specifications (NA - XRT dose administered within protocol specifications)
CL Item
Progression or relapse (Progression or relapse)
CL Item
Toxicity or treatment reaction (Toxicity or treatment reaction)
CL Item
Death (Death)
CL Item
Patient refused (Patient refused)
CL Item
Alternative RX given, specify RX (Alternative RX given, specify RX)
CL Item
Other reason, specify (Other reason, specify)
Werethereanydosemodificationsoradditions/omissionstoprotocoltreatmentotherreason,specify
Item
Were there any dose modifications or additions/omissions to protocol treatment other reason, specify (TREATMENT MODIFIED)
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
SplitCourseInterruption
Item
Split Course Interruption (Complete only if assigned split course. Total number of days interrupted for split between first and second course.)
text
SignatureofPersonCompletingThisForm
Item
Signature of Person Completing This Form
text
FormCompletionDate,Original
Item
Date
date
Total#oftreatmentdaysRTinterruptedfortoxicity.
Item
Total # of treatment days RT interrupted for toxicity.
text
Total#oftreatmentdaysRTinterruptedforotherreasons,specify
Item
Total # of treatment days RT interrupted for other reasons, specify
text
Total#oftreatmentdaysRTinterruptedforotherreasons,specify
Item
Total # of treatment days RT interrupted for other reasons, specify
text

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