ID

10573

Descripción

Radiation Therapy Oncology Group Phase III Lung Prophylactic Cranial RT Radiotherapy Summary Form NCT00048997 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

  1. 19/9/12 19/9/12 -
  2. 28/5/15 28/5/15 -
  3. 3/6/15 3/6/15 -
Subido en

3 de junio 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 NCT00048997

    No Instruction available.

    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

    Similar models

    No Instruction available.

    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
    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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