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Beschreibung:

On-Study Form Bladder Cancer NCT00014534 CALGB-90104 NCT00014534 NCI Cooperative Group On-Study Form-Revised (CALGB-90104) Combination Chemotherapy in Treating Patients With Bladder Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BE1B6E9C-942E-7181-E034-0003BA12F5E7

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BE1B6E9C-942E-7181-E034-0003BA12F5E7

Stichworte:

Klinische Studie [Dokumenttyp]

Harnblasentumoren

Versionen (3) ▾

26.08.12
09.01.15
21.08.15

Hochgeladen am:

21. August 2015

DOI:

Keine DOI zugewiesen. Für eine Beantragung loggen Sie sich ein.

Lizenz:

Creative Commons BY-NC 3.0 Legacy

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On-Study Form Bladder Cancer NCT00014534 CALGB-90104

Englisch

Details

No Instruction available.

StudyEvent: NCI Cooperative Group On-Study Form-Revised (CALGB-90104)
1. No Instruction available.

Muscle Invasive Bladder Disease: Prior Treatment Affecting The Bladder

Prior Intravesical Therapy (Note: If no, skip to Prior Surgery below)

Yes

No

Type of Prior Immunotherapy

BCG (BCG)

Interferon (Interferon)

Other (Other)

Number of Courses

Agent Start Date

Type of Prior Chemotherapy

Mmc (MMC)

Thiotepa (Thiotepa)

Other (Other)

Number of Courses

Prior Surgery (for urothelial disease)

Yes

No

Prior Surgery Type

Patient Previosly Had A Partial Cystectomy (Partial cystectomy)

Patient Previosly Had A Radical Cystectomy (radical cystectomy)

Patient Previosly Had A Turbt (TURBT)

Patient Previously Had Other Surgery, Specify (Other, specify)

TURBT, specify number

Prior surgery date

Any Other Prior Therapy

Yes

No

Prior Therapy Name

Prior Therapy Date

Chest X-ray assessment date

Chest X-ray results

Negative (negative)

Positive (positive)

Equivocal (equivocal)

Abdominal/pelvic CT assessment date

Not Done (not done)

Normal (normal)

Equivocal (equivocal)

Abnormal-disease Related (abnormal-disease related)

Abnormal-not Disease Related (abnormal-not disease related)

Unknown (unknown)

1000/ul

Peripheral Platelet Count

1000/uL

Bilirubin, total

mg/dL

mg/dL

mg/dL

Creatinine Clearance

mL/min

Alkaline Phosphatase

U/L

Alkaline Phosphatase ULN

U/L

U/L

U/L

Date form completed

Ccrr Module For Nci Cooperative Group On-study Form-revised (calgb-90104)

CALGB Study No.

CALGB Patient ID

Are data amended?

Yes (Yes)

Patient Initials

Participating group

Patient medical record number

Participating group protocol number

Institution/Affiliate

Participating Group Patient ID

Date of Initial Symptom

Has the patient had a prior history of superficial disease?

Yes

No

Number of Prior Occurrences of Papillary

Number of Prior Occurrence of CIS

Date of Initial Pathologic Diagnosis of muscle invasive bladder cancer

Date of Initial Pathologic Diagnosis of muscle invasive bladder cancer

Date of Current pathologic diagnosis for muscle invasive bladder cancer

Date of Most recent prior recurrence for muscle invasive bladder cancer

Histologic Type (mark all that apply)

Transitional Cell Carcinoma (Transitional cell carcinoma)

Other Specify (Other, specify)

Histologic Grade (check the highest grade)

Well Differentiated (G1)

Moderately Differentiated (G2)

Poorly Differentiated (G3)

Tumor Grade Cannot Be Assessed (GX)

Pathologic T Stage (Indicate highest stage at the current presentation of disease)

No Evidence Of Primary Tumor (T0)

Tumor Invades Subepithelial Connective Tissue (T1)

Tumor Invades Superficial Muscles (inner Half) (T2a)

Tumor Invades Deep Muscles (outer Half) (T2b)

Tumor Invades Perivesical Tissue Microscopically (T3a)

3 weitere Items in der Detailansicht.

Pathologic N Stage (Distant Metastasis)

No Regional Lymph Node Metastasis (N0)

Metastasis In A Single Lymph Node, 2 Cm Or Less In Greatest Dimension (N1)

Metastasis In A Single Lymph Node, More Than 2 Cm But Not More Than 5 Cm In Greatest Dimension; Or Multiple Lymph Nodes, None More Than 5 Cm In Greatest Dimension (N2)

Metastasis In A Lymph Node More Than 5 Cm In Greatest Dimension (N3)

Regional Lymph Nodes Cannot Be Assessed (Nx)

Pathologic M Stage

M0, According To Ajcc Staging Definitions (M0)

Lymph Node Type (unnamed)

Internal Iliac (Internal Iliac)

External Iliac (External Iliac)

Common Iliac (Common Iliac)

Hypogastric (Hypogastric)

Para-aortic (Para-aortic)

Other, Specify (Other, specify)

Lymph Node Involvement (unnamed)

Lymph Nodes Were Not Evaluated For Involvement (not evaluated)

Lymph Nodes Were Evaluated For Involvement, And They Were Positive (positive)

Lymph Nodes Were Evaluated For Involvement, And They Were Negative (negative)

Lymph Nodes Were Evaluated For Involvement, And They Were Equivocal (equivocal)

Unknown Whether The Lymph Nodes Were Evaluated For Involvement (unknown)

Number of Lymph Nodes Examined

Number of Positive Lymph Nodes

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Kontakt

Institut für Medizinische Informatik
Direktor: Prof. Dr. Martin Dugas
Albert-Schweitzer-Campus 1, A11
48149 Münster, Germany
E-Mail : imi@uni-muenster.de

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