ID

25174

Description

AMC-053 Lymphoma Response Form (LYR) Bortezomib, Ifosfamide, Carboplatin, and Etoposide, With or Without Rituximab, in Treating Patients With Relapsed or Refractory AIDS-Related Non-Hodgkin Lymphoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=8B73192C-C1AD-46D4-E040-BB89AD433800

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=8B73192C-C1AD-46D4-E040-BB89AD433800

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 8/28/17 8/28/17 -
Uploaded on

August 28, 2017

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Creative Commons BY-NC 3.0 Legacy
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AMC-053 Lymphoma Response Form (LYR)

English

This form is to be updated at each response assessment time point defined in the protocol

1 forms  
Extra Nodal Involvement Evaluation
Description

Extra Nodal Involvement Evaluation

Alias
UMLS CUI-1
C0012634
UMLS CUI-2
C1314939
UMLS CUI-3
C0220825
UMLS CUI-4
C1332051
Date of Last Clinical Assessment
Description

Follow-Up Date

Data type

date

Alias
NCI Thesaurus ObjectClass
C9305
NCI Thesaurus Property
C16033
NCI Thesaurus Property-2
C25365
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25367
UMLS CUI [1,1]
C1522577
UMLS CUI [1,2]
C0006826
UMLS CUI [1,3]
C0011008
Complete Response
Description

Complete Response

Alias
UMLS CUI-1
C0006826
UMLS CUI-2
C0677874
UMLS CUI-3
C1332051
Is complete response first observed
Description

CompleteResponseFirstObservedInd-2 (CR)

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C25755
NCI Thesaurus ObjectClass-2
C25250
NCI Thesaurus Property
C25509
NCI Thesaurus Property-2
C25599
NCI Thesaurus ValueDomain
C38147
UMLS CUI [1,1]
C0006826
UMLS CUI [1,2]
C0677874
Complete Response
Description

Complete Response First Observed Date

Data type

date

Alias
NCI Thesaurus ObjectClass
C25755
NCI Thesaurus ObjectClass-2
C25250
NCI Thesaurus Property
C25509
NCI Thesaurus Property-2
C25599
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25367
UMLS CUI [1,1]
C0006826
UMLS CUI [1,2]
C0677874
UMLS CUI [1,3]
C0011008
Is complete response confirmed
Description

CompleteResponseConfirmedInd-3 (CR)

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
NCI Thesaurus ObjectClass
C25755
NCI Thesaurus ObjectClass-2
C25250
NCI Thesaurus Property
C25458
UMLS CUI [1,1]
C0006826
UMLS CUI [1,2]
C0677874
UMLS CUI [1,3]
C0750484
Complete Response Confirmed Date
Description

CompleteResponseConfirmedDate (mm/dd/yyyy)

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C25755
NCI Thesaurus ObjectClass-2
C25250
NCI Thesaurus Property
C25458
UMLS CUI [1,1]
C0006826
UMLS CUI [1,2]
C0677874
UMLS CUI [1,3]
C0750484
UMLS CUI [1,4]
C0011008
Complete Response Unconfirmed
Description

Complete Response Unconfirmed

Alias
UMLS CUI-1
C0006826
UMLS CUI-2
C0677874
UMLS CUI-3
C1332051
Is complete response uncertain first observed
Description

UncertainCompleteResponseFirstObservedInd-2

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C25755
NCI Thesaurus ObjectClass-2
C25250
NCI Thesaurus ObjectClass-3
C47944
NCI Thesaurus Property
C25509
NCI Thesaurus Property-2
C25599
NCI Thesaurus ValueDomain
C38147
UMLS CUI [1,1]
C0006826
UMLS CUI [1,2]
C0677874
UMLS CUI [1,3]
C0087130
Complete Response uncertain (CRu) First Observed Date
Description

UncertainCompleteResponseNon-HodgkinLymphomaObservedDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C47944
NCI Metathesaurus ObjectClass
C0677874
NCI Thesaurus Property
C3211
NCI Thesaurus Property-2
C25599
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25367
UMLS CUI [1,1]
C0006826
UMLS CUI [1,2]
C0677874
UMLS CUI [1,3]
C0087130
UMLS CUI [1,4]
C0011008
Is complete response, uncertain, confirmed
Description

UncertainCompleteResponseConfirmedInd-2 (CRU)

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C25755
NCI Thesaurus ObjectClass-2
C25250
NCI Thesaurus ObjectClass-3
C47944
NCI Thesaurus Property
C25458
NCI Thesaurus ValueDomain
C38147
UMLS CUI [1,1]
C0006826
UMLS CUI [1,2]
C0677874
UMLS CUI [1,3]
C0087130
UMLS CUI [1,4]
C0750484
Complete Response Uncertain (CRu) Confirmed Date
Description

UncertainCompleteResponseConfirmedDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C25755
NCI Thesaurus ObjectClass-2
C25250
NCI Thesaurus ObjectClass-3
C47944
NCI Thesaurus Property
C25458
NCI Thesaurus ValueDomain
C25164
UMLS CUI [1,1]
C0006826
UMLS CUI [1,2]
C0677874
UMLS CUI [1,3]
C0087130
UMLS CUI [1,4]
C0750484
UMLS CUI [1,5]
C0011008
Partial Response
Description

Partial Response

Alias
UMLS CUI-1
C1521726
UMLS CUI-2
C1332051
Is partial response first observed
Description

PartialResponseFirstObservedInd-2 (PR)

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C25755
NCI Thesaurus ObjectClass-2
C25378
NCI Thesaurus Property
C25509
NCI Thesaurus Property-2
C25599
NCI Thesaurus ValueDomain
C38147
UMLS CUI [1]
C1521726
Partial Response
Description

Partial Response First Observed Date

Data type

date

Alias
NCI Thesaurus ObjectClass
C25755
NCI Thesaurus ObjectClass-2
C25378
NCI Thesaurus Property
C25509
NCI Thesaurus Property-2
C25599
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25367
UMLS CUI [1,1]
C1521726
UMLS CUI [1,2]
C0011008
Is partial response confirmed
Description

PartialResponseConfirmedInd-3 (PR)

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C25755
NCI Thesaurus ObjectClass-2
C25378
NCI Thesaurus Property
C25458
NCI Thesaurus ValueDomain
C38148
NCI Thesaurus ValueDomain-2
C25755
UMLS CUI [1,1]
C1521726
UMLS CUI [1,2]
C0750484
Partial Response Confirmed Date
Description

PartialResponseConfirmedDate (mm/dd/yyyy)

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C25755
NCI Thesaurus Property
C25458
NCI Thesaurus ObjectClass-2
C25378
UMLS CUI [1,1]
C1521726
UMLS CUI [1,2]
C0750484
UMLS CUI [1,3]
C0011008
Progressive Disease
Description

Progressive Disease

Alias
UMLS CUI-1
C1335499
UMLS CUI-2
C1332051
Has the patient been diagnosed with a new progression?
Description

Disease New Progression

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38147
NCI Thesaurus Property
C25586
NCI Thesaurus Property-2
C25331
NCI Thesaurus ObjectClass
C2991
UMLS CUI [1]
C1335499
Progressive Disease First Observed Date
Description

Progression First Observed Date

Data type

date

Alias
NCI Thesaurus ObjectClass
C25331
NCI Thesaurus Property
C25509
NCI Thesaurus Property-2
C25599
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25367
UMLS CUI [1,1]
C1335499
UMLS CUI [1,2]
C0011008
Please indicate the site of progression
Description

Disease Progression Site

Data type

integer

Alias
NCI Thesaurus ValueDomain
C13717
NCI Thesaurus Property
C25331
NCI Thesaurus ObjectClass
C2991
UMLS CUI [1,1]
C1515974
UMLS CUI [1,2]
C1335499
Central Nervous System Progression
Description

Central Nervous System Progression

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
NCI Thesaurus Property
C25331
NCI Thesaurus ObjectClass
C12438
UMLS CUI [1,1]
C0449389
UMLS CUI [1,2]
C1335499
CNS - leptomeninges
Description

Leptomeninges CNS Involved

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
NCI Thesaurus ObjectClass
C12438
NCI Thesaurus Property
C25547
NCI Thesaurus ObjectClass-2
C32979
UMLS CUI [1]
C0228126
UMLS CUI [2,1]
C0449389
UMLS CUI [2,2]
C1335499
Brain - parenchymal
Description

Brain Parenchymal Involved

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
NCI Thesaurus ObjectClass
C12439
NCI Thesaurus Property
C25547
NCI Thesaurus Property-2
C74601
UMLS CUI [1,1]
C0933845
UMLS CUI [1,2]
C0006104
UMLS CUI [2,1]
C0449389
UMLS CUI [2,2]
C1335499
Comments
Description

Comments

Alias
UMLS CUI-1
C1332051
UMLS CUI-2
C0947611
Comments
Description

Research Comments

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
UMLS CUI [1,1]
C0947611
UMLS CUI [1,2]
C1332051
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Similar models

This form is to be updated at each response assessment time point defined in the protocol

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Extra Nodal Involvement Evaluation
C0012634 (UMLS CUI-1)
C1314939 (UMLS CUI-2)
C0220825 (UMLS CUI-3)
C1332051 (UMLS CUI-4)
Follow-Up Date
Item
Date of Last Clinical Assessment
date
C9305 (NCI Thesaurus ObjectClass)
C16033 (NCI Thesaurus Property)
C25365 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
C1522577 (UMLS CUI [1,1])
C0006826 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
Item Group
Complete Response
C0006826 (UMLS CUI-1)
C0677874 (UMLS CUI-2)
C1332051 (UMLS CUI-3)
Is complete response first observed
Item
Is complete response first observed
boolean
C25755 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus ObjectClass-2)
C25509 (NCI Thesaurus Property)
C25599 (NCI Thesaurus Property-2)
C38147 (NCI Thesaurus ValueDomain)
C0006826 (UMLS CUI [1,1])
C0677874 (UMLS CUI [1,2])
Complete Response First Observed Date
Item
Complete Response
date
C25755 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus ObjectClass-2)
C25509 (NCI Thesaurus Property)
C25599 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
C0006826 (UMLS CUI [1,1])
C0677874 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
Is complete response confirmed
Item
Is complete response confirmed
boolean
C38148 (NCI Thesaurus ValueDomain)
C25755 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus ObjectClass-2)
C25458 (NCI Thesaurus Property)
C0006826 (UMLS CUI [1,1])
C0677874 (UMLS CUI [1,2])
C0750484 (UMLS CUI [1,3])
Complete Response Confirmed Date
Item
Complete Response Confirmed Date
date
C25164 (NCI Thesaurus ValueDomain)
C25755 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus ObjectClass-2)
C25458 (NCI Thesaurus Property)
C0006826 (UMLS CUI [1,1])
C0677874 (UMLS CUI [1,2])
C0750484 (UMLS CUI [1,3])
C0011008 (UMLS CUI [1,4])
Item Group
Complete Response Unconfirmed
C0006826 (UMLS CUI-1)
C0677874 (UMLS CUI-2)
C1332051 (UMLS CUI-3)
Is complete response uncertain first observed
Item
Is complete response uncertain first observed
boolean
C25755 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus ObjectClass-2)
C47944 (NCI Thesaurus ObjectClass-3)
C25509 (NCI Thesaurus Property)
C25599 (NCI Thesaurus Property-2)
C38147 (NCI Thesaurus ValueDomain)
C0006826 (UMLS CUI [1,1])
C0677874 (UMLS CUI [1,2])
C0087130 (UMLS CUI [1,3])
Complete Response uncertain (CRu) First Observed Date
Item
Complete Response uncertain (CRu) First Observed Date
date
C47944 (NCI Thesaurus ObjectClass)
C0677874 (NCI Metathesaurus ObjectClass)
C3211 (NCI Thesaurus Property)
C25599 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
C0006826 (UMLS CUI [1,1])
C0677874 (UMLS CUI [1,2])
C0087130 (UMLS CUI [1,3])
C0011008 (UMLS CUI [1,4])
Is complete response, uncertain, confirmed
Item
Is complete response, uncertain, confirmed
boolean
C25755 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus ObjectClass-2)
C47944 (NCI Thesaurus ObjectClass-3)
C25458 (NCI Thesaurus Property)
C38147 (NCI Thesaurus ValueDomain)
C0006826 (UMLS CUI [1,1])
C0677874 (UMLS CUI [1,2])
C0087130 (UMLS CUI [1,3])
C0750484 (UMLS CUI [1,4])
Complete Response Uncertain (CRu) Confirmed Date
Item
Complete Response Uncertain (CRu) Confirmed Date
date
C25755 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus ObjectClass-2)
C47944 (NCI Thesaurus ObjectClass-3)
C25458 (NCI Thesaurus Property)
C25164 (NCI Thesaurus ValueDomain)
C0006826 (UMLS CUI [1,1])
C0677874 (UMLS CUI [1,2])
C0087130 (UMLS CUI [1,3])
C0750484 (UMLS CUI [1,4])
C0011008 (UMLS CUI [1,5])
Item Group
Partial Response
C1521726 (UMLS CUI-1)
C1332051 (UMLS CUI-2)
Is partial response first observed
Item
Is partial response first observed
boolean
C25755 (NCI Thesaurus ObjectClass)
C25378 (NCI Thesaurus ObjectClass-2)
C25509 (NCI Thesaurus Property)
C25599 (NCI Thesaurus Property-2)
C38147 (NCI Thesaurus ValueDomain)
C1521726 (UMLS CUI [1])
Partial Response First Observed Date
Item
Partial Response
date
C25755 (NCI Thesaurus ObjectClass)
C25378 (NCI Thesaurus ObjectClass-2)
C25509 (NCI Thesaurus Property)
C25599 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
C1521726 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Is partial response confirmed
Item
Is partial response confirmed
boolean
C25755 (NCI Thesaurus ObjectClass)
C25378 (NCI Thesaurus ObjectClass-2)
C25458 (NCI Thesaurus Property)
C38148 (NCI Thesaurus ValueDomain)
C25755 (NCI Thesaurus ValueDomain-2)
C1521726 (UMLS CUI [1,1])
C0750484 (UMLS CUI [1,2])
Partial Response Confirmed Date
Item
Partial Response Confirmed Date
date
C25164 (NCI Thesaurus ValueDomain)
C25755 (NCI Thesaurus ObjectClass)
C25458 (NCI Thesaurus Property)
C25378 (NCI Thesaurus ObjectClass-2)
C1521726 (UMLS CUI [1,1])
C0750484 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
Item Group
Progressive Disease
C1335499 (UMLS CUI-1)
C1332051 (UMLS CUI-2)
Disease New Progression
Item
Has the patient been diagnosed with a new progression?
boolean
C38147 (NCI Thesaurus ValueDomain)
C25586 (NCI Thesaurus Property)
C25331 (NCI Thesaurus Property-2)
C2991 (NCI Thesaurus ObjectClass)
C1335499 (UMLS CUI [1])
Progression First Observed Date
Item
Progressive Disease First Observed Date
date
C25331 (NCI Thesaurus ObjectClass)
C25509 (NCI Thesaurus Property)
C25599 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
C1335499 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Item
Please indicate the site of progression
integer
C13717 (NCI Thesaurus ValueDomain)
C25331 (NCI Thesaurus Property)
C2991 (NCI Thesaurus ObjectClass)
C1515974 (UMLS CUI [1,1])
C1335499 (UMLS CUI [1,2])
CL.8
Code List
Please indicate the site of progression
CL Item
Original Site Only (1)
CL Item
New Site Only (2)
CL Item
New Site Plus Original Site (3)
Central Nervous System Progression
Item
Central Nervous System Progression
boolean
C38148 (NCI Thesaurus ValueDomain)
C25331 (NCI Thesaurus Property)
C12438 (NCI Thesaurus ObjectClass)
C0449389 (UMLS CUI [1,1])
C1335499 (UMLS CUI [1,2])
Leptomeninges CNS Involved
Item
CNS - leptomeninges
boolean
C38148 (NCI Thesaurus ValueDomain)
C12438 (NCI Thesaurus ObjectClass)
C25547 (NCI Thesaurus Property)
C32979 (NCI Thesaurus ObjectClass-2)
C0228126 (UMLS CUI [1])
C0449389 (UMLS CUI [2,1])
C1335499 (UMLS CUI [2,2])
Brain Parenchymal Involved
Item
Brain - parenchymal
boolean
C38148 (NCI Thesaurus ValueDomain)
C12439 (NCI Thesaurus ObjectClass)
C25547 (NCI Thesaurus Property)
C74601 (NCI Thesaurus Property-2)
C0933845 (UMLS CUI [1,1])
C0006104 (UMLS CUI [1,2])
C0449389 (UMLS CUI [2,1])
C1335499 (UMLS CUI [2,2])
Item Group
Comments
C1332051 (UMLS CUI-1)
C0947611 (UMLS CUI-2)
Research Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0947611 (UMLS CUI [1,1])
C1332051 (UMLS CUI [1,2])
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