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S0502 Advanced GIST PreStudy Form NCT00324987 S0502 Imatinib Mesylate With or Without Bevacizumab in Treating Patients With Metastatic or Unresectable Gastrointestinal Stromal Tumor Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=FCBF6A0D-F933-70F8-E034-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=FCBF6A0D-F933-70F8-E034-0003BA3F9857

Keywords:

Clinical Trial

Gastrointestinal Stromal Tumors

Registration

Versions (4)

9/19/12 9/19/12 -
8/8/14 8/8/14 - Martin Dugas
1/9/15 1/9/15 - Martin Dugas
6/12/15 6/12/15 -

Uploaded on:

June 12, 2015

DOI:

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Creative Commons BY-NC 3.0 Legacy

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S0502 Advanced GIST PreStudy Form NCT00324987

English 1

English

Details

No Instruction available.

1 forms

StudyEvent: S0502 Advanced GIST PreStudy Form
1. No Instruction available.

Header

SWOG Patient ID

SWOG Study No.

Registration Step

Patient Initials (L, F M)

Institution/Affiliate

Physician

Participating Group Name

Participating Group Study No.

Participating Group Patient ID

Eligibility Verification

Performance Status

Fully Active, Able To Carry On All Pre-disease Performance Without Restriction. (0)

Restricted In Physically Strenuous Activity But Ambulatory And Able To Carry Out Work Of A Light Or Sedentary Nature, E.g., Light Housework, Office Work. (1)

Ambulatory And Capable Of All Selfcare But Unable To Carry Out Any Work Activities. Up And About More Than 50% Of Waking Hours. (2)

Capable Of Only Limited Selfcare, Confined To Bed Or Chair More Than 50% Of Waking Hours. (3)

Completely Disabled. Cannot Carry On Any Selfcare. Totally Confined To Bed Or Chair. (4)

Hemoglobin (g/dl Document values in units listed Hematologic)

g/dL

ANC (mcL)

Peripheral Platelet Count (mcL)

1000/uL

Liver metastases (Hepatic)

Yes

Collection Date

Total Bilirubin (gm%)

Total bilirubin (mg/dl), ULN (gm%)

mg/dL

SGOT (gm%)

SGOT (AST) ULN (IU)

SGPT (U/L)

SGPT (ALT) ULN (U/L)

PTT (S Coagulation)

PTT ULN (S)

seconds

International Normalization Ratio (INR)

Serum Creatinine (mg% Renal)

mg/dL

Serum Creatinine ULN (mg%)

mg/dL

Urine Protein/Creatinine Ratio

Blood Pressure (Cardiovascular)

Blood Pressure

Cardiovascular/ Gastrointestinal Event

Date of last CVA, TIA, MI or unstable angina (if applicable)

Date of last abdominal fistula, gastrointestinal perforation, or intra-abdominal abscess (if applicable)

Current Disease Status

Site(s) of Disease (recommend to replace SWOG term "Fill in the box for each involved site" select all that apply)

Lymph Nodes (Lymph nodes)

Soft Tissue (Soft Tissue)

Retroperitoneum (Retroperitoneum)

Bone (Bone)

8 more items in the detailed view.

Was a complete resection done? (recommend to replace SWOG term "Was primary completely resected?")

Yes

Recurrent disease?

Yes

Tumor Grade

High Grade (High)

Low Grade (Low)

Not Assessed (Ungraded)

Distant metastases present?

Yes

Sarcoma Histologic Category

Epithelioid Carcinoma (Epithelioid)

Spindle Cell Carcinoma (Spindle cell)

Mixed Spindle Cell And Epithelioid Carcinoma (Mixed)

Date of Initial Pathologic Diagnosis (mm/dd/yyyy)

Height (cm)

Patient History

Does patient have history of adrenal cancer (Patient History indicative of Carney's triad)

Yes (Yes)

No (No)

Unknown (Unknown)

Prior Treatment Related To This Cancer

Prior Therapy Type (s select ALL that apply)

Systemic Chemotherapy With A Single Agent Regimen (Chemotherapy single agent systemic)

Systemic Chemotherapy With A Regimen Containing Multiple Agents (Chemotherapy multiple agents systemic)

Prior Therapy With Agents That Are Not Known To Cause Damage To Cycling Cells (Chemotherapy non-cytotoxic)

Non-systemic Chemotherapy Treatment Or Chemotherapy Not Described By Chemotherapy Single Agent Systemic Or Multi-agent Systemic (Chemotherapy NOS)

11 more items in the detailed view.

Number of prior chemotherapy regimens

Date Prior Chemotherapy Ended (traditional)

Setting of prior agent targeting VEGF, VEGFR, or PDGFR

Advanced (Advanced disease)

Adjuvant (Adjuvant)

None (No prior targeting agent)

Date of prior VEGF, VEGFR, PDGF targeted agent ended

Date of first recurrence following adjuvant therapy using agents targeting VEGF, VEGFR, PDGFR

Setting of prior imatinib (select all that apply)

Adjuvant (Adjuvant)

Advanced (Advanced disease)

None (No prior targeting agent)

Date of prior KIT targeted agent ended (If imatinib or other KIT targeted agent used in Adjuvant Setting, complete the following: )

Date of first recurrence following adjuvant therapy using agents targeting KIT

Date prior imatinib therapy started (If imatinib used in Advanced Disease Setting, complete the following:)

Was patient restaged after initiation of imatinib therapy

Yes

Does patient have clinical evidence of progressive disease

Yes

Prior radiation therapy stop date (if applicable)

Date of Most Recent Surgery (including open biopsy or significant traumatic injury, if applicable)

Date of last fine needle aspiration or core biopsy (if applicable)

Therapy specify (other)

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