ID

10350

Descripción

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

Palabras clave

Versiones (3)
  1. 19/9/12 19/9/12 - Philipp Bruland
  2. 28/5/15 28/5/15 -
  3. 3/6/15 3/6/15 -
Subido en

28 de mayo de 2015

DOI

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Licencia

Creative Commons BY-NC 3.0 Legacy
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Radiation Therapy Oncology Group Phase III Lung Prophylactic Cranial RT Radiotherapy Summary Form

Inglés

No Instruction available.

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

Header Module

Institution
Descripción

InstitutionName

Tipo de datos

text

Institution #
Descripción

NCIInstitutionNumber

Tipo de datos

text

Patient Name
Descripción

PatientName

Tipo de datos

text

Case #
Descripción

Case#

Tipo de datos

text

Patient ID #
Descripción

PatientID#

Tipo de datos

text

RADIOTHERAPY documentation
Descripción

RADIOTHERAPY documentation

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

AmendedDataInd

Tipo de datos

text

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

TreatmentBeginDate

Tipo de datos

date

LAST DATE PROTOCOL THERAPY WAS GIVEN
Descripción

ProtocolTreatmentAdministeredEndDate

Tipo de datos

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)
Descripción

PrimaryTumorSite,DOSESUMMARY

Tipo de datos

text

Dose (Gy)
Descripción

Dose(Gy)

Tipo de datos

text

Total to Primary Site
Descripción

RTTotalFractionCount

Tipo de datos

double

Regional Nodes, Dose Summary
Descripción

Local-RegionalLymphNodeRadiationTherapyAdministeredDose

Tipo de datos

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
Descripción

Fractions

Tipo de datos

text

Fractions
Descripción

Fractions

Tipo de datos

text

Dose (Gy)
Descripción

Dose(Gy)

Tipo de datos

text

Nodal Sites
Descripción

LymphNodesType

Tipo de datos

text

Other volume, specify
Descripción

Othervolume,specify

Tipo de datos

text

Critical Structures
Descripción

RadiationTherapyCriticalAnatomicSite

Tipo de datos

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)
Descripción

RTMaximumDose,CriticalStructures

Tipo de datos

double

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

DoseModification(Change)

Tipo de datos

text

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

Werethereanydosemodificationsoradditions/omissionstoprotocoltreatmentotherreason,specify

Tipo de datos

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.)
Descripción

SplitCourseInterruption

Tipo de datos

text

Signature of Person Completing This Form
Descripción

SignatureofPersonCompletingThisForm

Tipo de datos

text

Date
Descripción

FormCompletionDate,Original

Tipo de datos

date

Total # of treatment days RT interrupted for toxicity.
Descripción

Total#oftreatmentdaysRTinterruptedfortoxicity.

Tipo de datos

text

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

Total#oftreatmentdaysRTinterruptedforotherreasons,specify

Tipo de datos

text

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

Total#oftreatmentdaysRTinterruptedforotherreasons,specify

Tipo de datos

text

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Similar models

No Instruction available.

1 formularios
  1. StudyEvent: Radiation Therapy Oncology Group Phase III Lung Prophylactic Cranial RT Radiotherapy Summary Form
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
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
CL.1
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)
CL.2
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
CL.3
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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