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)
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)
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)
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
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)
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)
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)
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)
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)
Item
Pathologic diagnosis (Required field)
text
C3208 (NCI Thesaurus ObjectClass)
C0024299 (UMLS 2011AA ObjectClass)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
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)
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)
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)
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 Item
Myeloperoxidase (Myeloperoxidase)
C0027021 (NCI Metathesaurus)
CL Item
Lysozyme (Muramidase) (Lysozyme (Muramidase))
CL Item
Cd45 (CD45 (LCA))
CL Item
Terminal Transferase (tdt) (TDT)
CL Item
EBV LMP (EBV LMP)
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
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))
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)
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)
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)
Code List
TDT Method (One must be chosen)
CL Item
Flow Cytometry, Not Otherwise Specified (Flow cytometry)
CL Item
Immunofluorescence (Immunofluorescence)
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)
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)
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)
Code List
Fixative used (BIOPSY TISSUE PROCESSING DETAILS)
CL Item
Formalin (Formalin)
C0949307 (NCI Metathesaurus)
CL Item
Zinc Formalin (Zinc Formalin)
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)
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)
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)