PatientStudyID,CoordinatingGroup
Item
Patient ID No. (Study No.)
text
PatientInitialsName
Item
Patient Initials (f m fl sl)
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
PatientBirthDate
Item
Patient's Date of Birth (day)
date
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
ParticipatingCenter/Affiliate
Item
Participating Center/Affiliate
text
ParticipatingGroupCode
Item
Center Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
SpecimenIdentifierNumber
Item
Specimen ID Number
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
Adjacentnormaltissueblockspecimennumber
Item
Adjacent normal tissue block specimen number
text
Primarytumorslidespecimennumber
Item
Primary tumor slide specimen number
text
Adjacentnormalbreasttissueslidespecimennumber
Item
Adjacent normal breast tissue slide specimen number
text
Item
This form is being completed for
text
C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C12971 (NCI Thesaurus ObjectClass)
C0006141 (UMLS 2011AA ObjectClass)
C25306 (NCI Thesaurus Property)
C0441987 (UMLS 2011AA Property)
Code List
This form is being completed for
CL Item
Left Breast/side (Left breast/side)
CL Item
Right Breast/side (Right breast/side)
PathologicPrimaryTumorSize
Item
Pathologic primary tumor size. Maximum diameter of invasive component. (cm )
double
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)
Item
Histological type (Dominant)
text
Code List
Histological type (Dominant)
CL Item
invasive ductal (NOS) (invasive ductal (NOS))
CL Item
medullary (medullary)
CL Item
medullary-atypical (medullary-atypical)
CL Item
invasive lobular - classic type (invasive lobular - classic type)
CL Item
invasive lobular - variant type (invasive lobular - variant type)
CL Item
mucinous (colloid) (mucinous (colloid))
CL Item
mucinous (colloid) - variant (mucinous (colloid) - variant)
CL Item
tubular (tubular)
CL Item
tubular-variant (tubular-variant)
CL Item
invasive ductal with predominant intraductal component (invasive ductal with predominant intraductal component)
CL Item
intraductal (in situ) carcinoma, high grade (intraductal (in situ) carcinoma, high grade)
CL Item
intraductal (in situ) carcinoma, moderate grade (intraductal (in situ) carcinoma, moderate grade)
CL Item
intraductal (in situ) carcinoma, low grade (intraductal (in situ) carcinoma, low grade)
CL Item
invasive cribriform, pure (invasive cribriform, pure)
CL Item
invasive cribriform, mixed (invasive cribriform, mixed)
CL Item
in situ lobular carcinoma (in situ lobular carcinoma)
CL Item
no cancer on slide (no cancer on slide)
CL Item
other, specify (other, specify)
HistologicType,OtherName
Item
other, (specify)
text
Totalpoints-Bloom,Richardson,Elston(Grade)
Item
Total points - Bloom, Richardson, Elston (Grade) (If not available, complete Q4.)
text
TubuleFormation
Item
Tubule formation
text
Nuclearpleomorphism
Item
Nuclear pleomorphism
text
Mitoses
Item
Mitoses
text
Item
Differentiation (select one)
text
Code List
Differentiation (select one)
CL Item
Tumor Is Well Differentiated According To Who Grading System (Well differentiated)
CL Item
Tumor Is Moderately Differentiated According To Who Grading System (Moderately differentiated)
CL Item
Tumor Is Poorly Differentiated According To Who Grading System (Poorly differentiated)
Item
Invasive cancer
text
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C14159 (NCI Thesaurus ObjectClass)
C0205281 (UMLS 2011AA ObjectClass)
C15232 (NCI Thesaurus Property)
C0728940 (UMLS 2011AA Property)
C25563 (NCI Thesaurus Property)
C0205284 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
Code List
Invasive cancer
CL Item
<= 1 Mm, But Not Involved (<= 1 mm, but not involved)
CL Item
> 1 And <= 10 Mm (> 1 and <= 10 mm)
CL Item
> 10 Mm (> 10 mm)
CL Item
Not Involved, But Distance Not Assessable (Not involved, but distance not assessable)
Item
DCIS
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C15232 (NCI Thesaurus Property)
C0728940 (UMLS 2011AA Property)
C2924 (NCI Thesaurus ObjectClass)
C0007124 (UMLS 2011AA ObjectClass)
C25563 (NCI Thesaurus Property)
C0205284 (UMLS 2011AA Property)
CL Item
<= 1 Mm, But Not Involved (<= 1 mm, but not involved)
CL Item
> 1 And <= 10 Mm (> 1 and <= 10 mm)
CL Item
> 10 Mm (> 10 mm)
CL Item
Not Involved, But Distance Not Assessable (Not involved, but distance not assessable)
Item
Was there invasion of vessels around primary tumor? (select one)
text
Code List
Was there invasion of vessels around primary tumor? (select one)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Not Able To Assess (Not able to assess)
Item
Score by immunohistochemistry
text
Code List
Score by immunohistochemistry
CL Item
0 (0)
C0919414 (NCI Metathesaurus)
CL Item
Not Done (Not done)
CL281691 (NCI Metathesaurus)
Item
Immunohistochemistry Kit or Test Type
text
Code List
Immunohistochemistry Kit or Test Type
CL Item
Dako Herceptest [tm] (DAKO Herceptest [TM])
CL Item
Other, Specify (Other, specify)
Other,specify(assay)
Item
Other, specify (assay)
text
Item
By FISH
text
C16491 (NCI Thesaurus ObjectClass)
C0010819 (UMLS 2011AA ObjectClass)
C17563 (NCI Thesaurus ObjectClass)
C0162789 (UMLS 2011AA ObjectClass)
C25218 (NCI Thesaurus ValueDomain)
C1948041 (UMLS 2011AA ValueDomain)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
CL Item
Amplified (Amplified)
CL Item
Normal Copy Number (Normal copy number)
CL Item
Not Done (Not done)
CL281691 (NCI Metathesaurus)
CL Item
Polysomic (Polysomic)
CL Item
Other, Specify (Other, specify)
FISHKitorTestType,Other
Item
Other, specify (assay)
double
Byothertechnique,(Her2/neu)
Item
By other technique, (Her2/neu)
text
Item
Her2/neu status, (by other technique)
text
Code List
Her2/neu status, (by other technique)
CL Item
Negative (Negative)
C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)
CL Item
Not Done (Not done)
CL Item
Positive (Positive)
C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)
AxillaryNodeExaminedTotalCount
Item
Total number examined
double
C25304 (NCI Thesaurus ValueDomain)
C0439810 (UMLS 2011AA ValueDomain)
C25500 (NCI Thesaurus Property)
C0332128 (UMLS 2011AA Property)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
C12904 (NCI Thesaurus ObjectClass)
C0729594 (UMLS 2011AA ObjectClass)
Numberofpositiveaxillarylymphnodes
Item
Number of metastatic axillary lymph nodes
double
Item
Extracapsular Extension
text
Code List
Extracapsular Extension
CL Item
No (no)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Isolated tumor cells only
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C25549 (NCI Thesaurus ObjectClass)
C0205409 (UMLS 2011AA ObjectClass)
C12922 (NCI Thesaurus ObjectClass)
C0597032 (UMLS 2011AA ObjectClass)
Code List
Isolated tumor cells only
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
AxillarySentinelLymphNodeExaminedTotalCount
Item
Total number examined
double
C13351 (NCI Thesaurus ObjectClass)
C0004454 (UMLS 2011AA ObjectClass)
C12947 (NCI Thesaurus ObjectClass)
C1522495 (UMLS 2011AA ObjectClass)
C25500 (NCI Thesaurus Property)
C0332128 (UMLS 2011AA Property)
C25304 (NCI Thesaurus ValueDomain)
C0439810 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
MetastaticAxillarySentinelLymphNodeExaminedCount
Item
Number of metastatic axillary sentinel lymph nodes
double
C14174 (NCI Thesaurus ObjectClass)
C0036525 (UMLS 2011AA ObjectClass)
C13351 (NCI Thesaurus ObjectClass)
C0004454 (UMLS 2011AA ObjectClass)
C12947 (NCI Thesaurus ObjectClass)
C1522495 (UMLS 2011AA ObjectClass)
C25500 (NCI Thesaurus Property)
C0332128 (UMLS 2011AA Property)
C25304 (NCI Thesaurus ValueDomain)
C0439810 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
Item
Largest tumor deposit
text
Code List
Largest tumor deposit
CL Item
Isolated Tumor Cells Alone (Isolated tumor cells alone)
CL Item
Macrometastases (Macrometastases)
CL Item
Micrometastases (Micrometastases)
CL Item
None Detected (None detected)
Item
Largest tumor deposit
text
Code List
Largest tumor deposit
CL Item
Isolated Tumor Cells Alone (Isolated tumor cells alone)
CL Item
Macrometastases (Macrometastases)
CL Item
Micrometastases (Micrometastases)
CL Item
None Detected (None detected)
InternalMammarySentinelNodeExaminedTotalNumber
Item
Total number examined
double
C12947 (NCI Thesaurus ObjectClass)
C1522495 (UMLS 2011AA ObjectClass)
C25234 (NCI Thesaurus ObjectClass)
C0205102 (UMLS 2011AA ObjectClass)
C43595 (NCI Thesaurus ObjectClass)
C0006141 (UMLS 2011AA ObjectClass)
C25500 (NCI Thesaurus Property)
C0332128 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25304 (NCI Thesaurus ValueDomain)
C0439810 (UMLS 2011AA ValueDomain)
MetastaticInternalMammarySentinelNodeExaminedCount
Item
Number of metastatic internal mammary sentinel nodes
double
C14174 (NCI Thesaurus ObjectClass)
C0036525 (UMLS 2011AA ObjectClass)
C12947 (NCI Thesaurus ObjectClass)
C1522495 (UMLS 2011AA ObjectClass)
C25234 (NCI Thesaurus ObjectClass)
C0205102 (UMLS 2011AA ObjectClass)
C43595 (NCI Thesaurus ObjectClass)
C0006141 (UMLS 2011AA ObjectClass)
C25500 (NCI Thesaurus Property)
C0332128 (UMLS 2011AA Property)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
Item
Form completed by (select one)
text
Code List
Form completed by (select one)
CL Item
Pathologist (Pathologist)
CL Item
Investigator (Investigator)
Comments
Item
Comments
text
PathologistorInvestigator'sSignature
Item
Investigator/Pathologist Signature
text
InvestigatorSignatureDate
Item
Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ValueDomain)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)