ID

11291

Description

ANHL01P1: Institutional Pathology Form [reload] NCT00057811 Rituximab, Rasburicase, and Combination Chemotherapy in Treating Young Patients With Newly Diagnosed Advanced B-Cell Leukemia or Lymphoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BA57175F-244D-0585-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BA57175F-244D-0585-E034-0003BA12F5E7

Keywords

Uploaded on

June 27, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy

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ANHL01P1: Institutional Pathology Form [reload] NCT00057811

model
Details

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1 forms

StudyEvent: ANHL01P1: Institutional Pathology Form [reload]
1. No Instruction available.

Name

Type

Description | Question | Decode (Coded Value)

Data type

Alias

Header

Item Group

Header

Institution Name

Item

Name

text

C25191 (NCI Thesaurus ValueDomain)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C21541 (NCI Thesaurus ValueDomain-2)
C25364 (NCI Thesaurus Property)

Protocol ID COG

Item

Study Number

text

C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1516477 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)

PatientCOGIdentifierNumber

Item

COG Number

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)
C39353 (NCI Thesaurus Property-2)
C1516477 (UMLS 2011AA Property-2)

Patient Name

Item

Patient Name

text

C25191 (NCI Thesaurus ValueDomain)
C1299487 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)

Form Completion Date

Item

Today's date

date

C19464 (NCI Thesaurus ObjectClass)
C1549507 (UMLS CUI-1)
C25250 (NCI Thesaurus Property)
C25604 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)

DataEnteredDate

Item

Date worksheet entered into RDE

date

C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C37949 (NCI Thesaurus Property)
C1521975 (UMLS 2011AA Property)

Pathology evaluation

Item Group

Pathology evaluation

ReviewingPathologistName

Item

Institutional Pathologist (Name)

text

C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C17723 (NCI Thesaurus ObjectClass)
C0334866 (UMLS 2011AA ObjectClass)
C25661 (NCI Thesaurus ObjectClass-2)
C1704362 (UMLS 2011AA ObjectClass-2)

SpecimenAccessionNumber

Item

Institutional surgical pathology number(s) (Must be able to accept numbers and letters)

float

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25402 (NCI Thesaurus Property)
C1510755 (UMLS 2011AA Property)

SpecimenLaboratoryProcedureCollectionDate

Item

Date sample obtained from patient (mm/dd/yyyy)

date

C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25453 (NCI Thesaurus Property)
C1516698 (UMLS 2011AA Property)
C25294 (NCI Thesaurus Property-2)
C0022885 (UMLS 2011AA Property-2)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)

SpecimenCollectedPeriodType

Item

Time sample obtained (One must be chosen)

text

C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)

CL.1

Code List

Time sample obtained (One must be chosen)

CL Item

Sample Or Specimen Collected Before Patient Received Treatment For Cancer (Pre-treatment (at study entry))

CL Item

Any other time after study entry (Any other time after study entry)

CL Item

Death (Death)

CL Item

Other Specify (Other)

CL Item

Sample Or Specimen Collected Before Patient Was Diagnosed With Cancer (Pre-diagnosis)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

CL Item

Sample Or Specimen Collected After Patient Received Treatment For Cancer (Post-treatment)

SpecimenCollectedPeriodSpecify

Item

please specify [time sample obtained] (Required if #4 is chosen for time sample obtained.)

text

C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)

SpecimenCollectedMethodType

Item

Method for obtaining tissue samples (Required field)

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C16847 (NCI Thesaurus Property)
C0449851 (UMLS 2011AA Property)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C25452 (NCI Thesaurus Property-2)

CL.2

Code List

Method for obtaining tissue samples (Required field)

CL Item

Sample Or Specimen Collected Via Biopsy (Surgical biopsy)

CL Item

Sample Or Specimen Collected Via Biopsy (Needle core biopsy)

CL Item

Sample Or Specimen Collected Via Fine Needle Aspiration (Fine needle aspiration)

CL Item

Cytology (Cytology)

CL Item

Sample Or Specimen Collected Via Pleural Effusion (Body fluid cytology)

CL Item

(pleural effusion or ascites fluid ((pleural effusion or ascites fluid)

CL Item

Bone marrow aspirate (Bone marrow aspirate)

CL Item

Bone marrow biopsy (Bone marrow biopsy)

CL Item

Sample Or Specimen Collected Via Abdominal Effusion Or Ascites (Abdominal/ascites effusion)

CL Item

Sample Or Specimen Collected Via Bronchial Alveolar Lavage (Bronchial alveolar lavage (BAL))

CL Item

Sample Or Specimen Collected Via Bronchial Brushing Or Washing (Bronchial brushing/washing)

CL Item

Sample Or Specimen Collected Via Mediastinoscopy (Mediastinoscopy)

CL Item

Other Specify (Other, specify)

CL Item

Sample Or Specimen Collected Via Pericardial Effusion (Pericardial effusion)

CL Item

Sample Or Specimen Collected Via Pleural Lavage (Pleural lavage)

CL Item

Sample Or Specimen Collected Via Induced Sputum (Sputum, induced)

CL Item

Sample Or Specimen Collected Via Spontaneous Sputum (Sputum, spontaneous)

LeukemiaSpecimenCellSourceType

Item

Source of tissue samples (Required field)

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C3161 (NCI Thesaurus ObjectClass)
C0023418 (UMLS 2011AA ObjectClass)
C12508 (NCI Thesaurus Property)
C0007634 (UMLS 2011AA Property)
C19157 (NCI Thesaurus ObjectClass-2)
C0370003 (UMLS 2011AA ObjectClass-2)
C25365 (NCI Thesaurus Property-2)
C0678257 (UMLS 2011AA Property-2)

CL.3

Code List

Source of tissue samples (Required field)

CL Item

Primary tumor (Primary tumor)

CL Item

Pleural Fluid (Pleural effusion or ascites)

C0225778 (NCI Metathesaurus)

CL Item

Other Specify (Other site of tumor, specify below)

CL Item

Bone Biopsy (Bone biopsy)

CL Item

Bone Marrow (Bone marrow)

C12431 (NCI Thesaurus)
C0005953 (UMLS 2011AA)

CL Item

Cerebrospinal Fluid (Cerebrospinal fluid)

C12692 (NCI Thesaurus)
C0007806 (UMLS 2011AA)

CL Item

Lymph Node (Lymph node)

C12745 (NCI Thesaurus)
C0024204 (UMLS 2011AA)

CL Item

Peripheral Blood (Peripheral blood)

C0229664 (NCI Metathesaurus)

CL Item

Peritoneal Fluid (Peritoneal fluid)

CL Item

Soft Tissue Mass (Soft tissue mass)

C0457193 (NCI Metathesaurus)

SpecimenCellSourceSpecify

Item

please specify source [of tissue samples]

text

C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C12508 (NCI Thesaurus Property)
C0007634 (UMLS 2011AA Property)
C25683 (NCI Thesaurus Property-2)
C0449416 (UMLS 2011AA Property-2)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)

DiseasePrimarySiteText

Item

and primary tumor site (Text field)

text

C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C25251 (NCI Thesaurus Property-2)
C0205225 (UMLS 2011AA Property-2)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)

LymphomaPathologicDiagnosisType

Item

Pathologic diagnosis (Required field)

text

C3208 (NCI Thesaurus ObjectClass)
C0024299 (UMLS 2011AA ObjectClass)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)

CL.4

Code List

Pathologic diagnosis (Required field)

CL Item

Lymphoblastic Lymphoma (Lymphoblastic Lymphoma)

CL Item

Large Cell Lymphoma (Large cell lymphoma)

CL Item

Small, Non-cleaved Cell Lymphoma (Small, non-cleaved cell lymphoma)

CL Item

Other Non-hodgkin's Lymphoma (Other non-Hodgkin's lymphoma)

CL Item

Other Non-hodgkin's Lymphoma Subtype, Unknown (Other non-Hodgkin's lymphoma subtype, unknown)

CL Item

Other Malignancy, Specify (Other malignancy, specify ICD-O code below))

CL Item

Unknown/not Evaluated (Unknown/Not evaluated)

PrimaryCancerDiagnosisICD-OCode

Item

please fill in the ICD-O code of the pathologic diagnosis (If option #4 or #6 was chosen in the above question,)

text

C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)

ImmunophenotypeType

Item

Immunophenotype (One must be chosen)

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C20072 (NCI Thesaurus ObjectClass)
C0079611 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)

CL.5

Code List

Immunophenotype (One must be chosen)

CL Item

B-cell Immunophenotype (B-cell)

CL Item

T-cell Immunophenotype (T-cell)

CL Item

Mixed Cells Immunophenotype (B & T cell/Bi-phenotype)

CL Item

Non-t/non-b Cell Immunophenotype (Non-T/Non-B)

CL Item

Not Done (Not Done)

CL Item

Indeterminate Immunophenotype (Unknown)

CL Item

Other Specified Immunophenotype (Other, specify)

LymphomaHistologicCategoryCode

Item

Lymphoma Classification Diagnosis (See Appendix ? for explanation of Diagnosis Code to be entered - Melissa to assign appendix number)

text

C3208 (NCI Thesaurus ObjectClass)
C0024299 (UMLS 2011AA ObjectClass)
C25161 (NCI Thesaurus Property)
C0008902 (UMLS 2011AA Property)

Results from fresh or frozen tissue

Item Group

Results From Fresh Or Frozen Tissue

Immunophenotype Antigen Type

Item

Antigen Type

text

C25284 (NCI Thesaurus ValueDomain)
C20072 (NCI Thesaurus ObjectClass)
C0003320 (NCI Metathesaurus Property)
C0332307 (UMLS CUI-1)
C0079611 (UMLS CUI-2)

CL.9

Code List

Antigen Type

CL Item

Cd2 (CD1)

CL Item

Cd2 (CD2)

CL Item

CD3 (CD3)

CL Item

Cd4 (CD4)

CL Item

Cd5 (CD5)

CL Item

Cd7 (CD7)

CL Item

Cd8 (CD8)

CL Item

Cd43 (CD43)

CL Item

Cd45 (CD45RO)

CL Item

Cd20 (CD20)

CL Item

CD22 (CD22)

CL Item

Cd24 (CD24)

CL Item

Cd45 (CD45RA)

CL Item

CD79a (CD79a)

CL Item

CD80 (CD80)

CL Item

Kappa (Kappa)

CL Item

Lambda (Lambda)

CL Item

Myeloperoxidase (Myeloperoxidase)

C0027021 (NCI Metathesaurus)

CL Item

Lysozyme (Muramidase) (Lysozyme (Muramidase))

CL Item

Cd15 (CD15)

CL Item

CD68 (CD68)

CL Item

Cd10 (CD10)

CL Item

Cd25 (CD25)

CL Item

Cd30 (CD30)

CL Item

Cd34 (CD34)

CL Item

Cd45 (CD45 (LCA))

CL Item

ALK-1 (ALK-1)

CL Item

Terminal Transferase (tdt) (TDT)

CL Item

EBV LMP (EBV LMP)

CL Item

EBER (EBER)

CL Item

Cd22 Intracytoplasmic (CD22 intracytoplasmic)

CL Item

Cd22 Surface (CD22 surface)

CL Item

Cd3 Intracytoplasmic (CD3 intracytoplasmic)

CL Item

Cd3 Surface (CD3 surface)

CL Item

Cd79a Intracytoplasmic (CD79a intracytoplasmic)

CL Item

Cd79a Surface (CD79a surface)

CL Item

Cd79b Intracytoplasmic (CD79b intracytoplasmic)

CL Item

Cd79b Surface (CD79b surface)

CL Item

Glycophorin (Glycophorin)

C0017954 (NCI Metathesaurus)

CL Item

Ig-kappa Intracytoplasmic (Ig-kappa intracytoplasmic)

CL Item

Ig-kappa Surface (Ig-kappa surface)

CL Item

Ig-lambda Intracytoplasmic (Ig-lambda intracytoplasmic)

CL Item

Ig-lambda Surface (Ig-lambda surface)

CL Item

Iga Surface (IgA surface)

CL Item

Igd Surface (IgD surface)

CL Item

Igg Surface (IgG surface)

CL Item

Igm Intracytoplasmic (IgM intracytoplasmic)

CL Item

Igm Surface (IgM surface)

CL Item

Ki67 (Ki67)

CL Item

Lactoferrin (Lactoferrin)

C0022942 (NCI Metathesaurus)

CL Item

Lung-resistance-related Or Major Vault Protein (lrp/mvp) (Lung-resistance-related or major vault protein (LRP/MVP))

CL Item

Multidrug Resistance-associated Protein (mrp) (Multidrug resistance-associated protein (MRP))

CL Item

Other (Other)

C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)

CL Item

P-glycoprotein (pgp/mdr1) (P-glycoprotein (Pgp/MDR1))

ImmunophenotypeAntigenInd

Item

Results from paraffin embedded tissue (One must be chosen)

text

C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C20072 (NCI Thesaurus ObjectClass)
C0079611 (UMLS 2011AA ObjectClass)
C0003320 (NCI Metathesaurus Property)

CL.10

Code List

Results from paraffin embedded tissue (One must be chosen)

CL Item

Yes (Positive)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

CL Item

No (Negative)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

CL Item

Indeterminate (Equivocal)

C48658 (NCI Thesaurus)
C0205258 (UMLS 2011AA)

CL Item

Not Done (Not done/Not evaluable)

CL281691 (NCI Metathesaurus)

ImmunophenotypeMethodType

Item

TDT Method (One must be chosen)

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C16847 (NCI Thesaurus Property)
C0449851 (UMLS 2011AA Property)
C20072 (NCI Thesaurus ObjectClass)
C0079611 (UMLS 2011AA ObjectClass)

CL.8

Code List

TDT Method (One must be chosen)

CL Item

Flow Cytometry, Not Otherwise Specified (Flow cytometry)

CL Item

Immunofluorescence (Immunofluorescence)

CL Item

Both (Both)

CL Item

Unknown (Unknown)

CL Item

Flow Cytometry, 2 Color (Flow cytometry, 2 color)

CL Item

Flow Cytometry, 3 Color (Flow cytometry, 3 color)

CL Item

Flow Cytometry, 4 Or More Color (Flow cytometry, 4 or more color)

CL Item

Immunohistochemistry (Immunohistochemistry)

C16722 (NCI Thesaurus)

CL Item

Other Specify (Other, specify)

Results from paraffin embedded tissue

Item Group

Results From Paraffin Embedded Tissue

PathologySpecimenCentralReviewerSubmissionInd-2

Item

SLIDE/TISSUE SUBMISSION: For Central Review? (One must be chosen)

boolean

C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C18189 (NCI Thesaurus ObjectClass-2)
C0030664 (UMLS 2011AA ObjectClass-2)
C25694 (NCI Thesaurus Property)
C1515022 (UMLS 2011AA Property)
C51807 (NCI Thesaurus Property-2)
C1707338 (UMLS 2011AA Property-2)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)

SpecimenFrozenInd-2

Item

Is any frozen tissue available? (One must be chosen)

boolean

C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL267638 (NCI Metathesaurus Property)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)

SpecimenFixativeType

Item

Fixative used (BIOPSY TISSUE PROCESSING DETAILS)

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C498 (NCI Thesaurus Property)
C0016184 (UMLS 2011AA Property)

CL.13

Code List

Fixative used (BIOPSY TISSUE PROCESSING DETAILS)

CL Item

Formalin (Formalin)

C0949307 (NCI Metathesaurus)

CL Item

Zinc Formalin (Zinc Formalin)

CL Item

B5 (B5)

CL Item

Other (Other)

C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

SpecimenFixativeSpecify

Item

please specify [biopsy tissue processing details, fixative used] (Probably should accept numbers and letters)

text

C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C498 (NCI Thesaurus Property)
C0016184 (UMLS 2011AA Property)

SpecimenFixativeHoursType

Item

Number of hours in fixative before processing

text

C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C498 (NCI Thesaurus Property)
C0016184 (UMLS 2011AA Property)

CL.14

Code List

Number of hours in fixative before processing

CL Item

24 Hours Or Less (24 hours or less)

CL Item

25-48 Hours (25-48 hours)

CL Item

Greater Than 48 Hours (>48 hours)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

SpecimenCloneExaminedInd-2

Item

Is there evidence of clonality by gene rearrangement? (Required field)

boolean

C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C25500 (NCI Thesaurus Property)
C0332128 (UMLS 2011AA Property)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)

CCRR MODULE

Item Group

Ccrr Module For Anhl01p1: Institutional Pathology Form [reload]

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ID

Description

Link

Keywords

Versions (4)

Uploaded on

DOI

License

Model comments :

Itemgroup comments for :

Item comments for :

ANHL01P1: Institutional Pathology Form [reload] NCT00057811

No Instruction available.

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