ID

25264

Description

AMC-053 Baseline Lymphoma Disease Activity and Assessment Form (LAA) 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-C055-46D4-E040-BB89AD433800

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=8B73192C-C055-46D4-E040-BB89AD433800

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 8/29/17 8/29/17 -
Uploaded on

August 29, 2017

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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NCT00598169 On-Study - AMC-053 Baseline Lymphoma Disease Activity and Assessment Form (LAA) - 3122745v1.0

English

Complete this form at baseline only

1 forms  
  1. StudyEvent: AMC-053 Baseline Lymphoma Disease Activity and Assessment Form (LAA)
    1. Complete this form at baseline only
Header - Baseline Lymphoma Disease Activity and Assessment Form
Description

Header - Baseline Lymphoma Disease Activity and Assessment Form

Alias
UMLS CUI-1
C0024299
UMLS CUI-2
C1320722
UMLS CUI-3
C0220825
UMLS CUI-4
C1332051
Visit Number
Description

Visit number

Data type

integer

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C16696
NCI Thesaurus Property
C25385
UMLS CUI [1]
C1549755
Lymphoma Disease Activity and Assessment
Description

Lymphoma Disease Activity and Assessment

Alias
UMLS CUI-1
C3869583
UMLS CUI-2
C0220825
UMLS CUI-3
C0024299
UMLS CUI-4
C1332051
Modified Ann Arbor Stage
Description

LymphomaAnnArborLymphomaStagingSystemClassificationStage

Data type

integer

Alias
NCI Thesaurus ObjectClass
C3208
NCI Thesaurus ValueDomain
C16899
NCI Thesaurus Property
C25161
UMLS CUI [1]
C0432516
Recurring, drenching night sweats during the previous month
Description

LymphomaSweatingSymptomInd-3 (Does the participant have any of the following symptoms at the time of registration)

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
NCI Thesaurus ObjectClass
C3208
NCI Thesaurus Property
C4876
NCI Thesaurus Property-2
C36172
UMLS CUI [1]
C0028081
Unexplained, persistent fever >38 degrees C
Description

LymphomaFeverSymptomInd-3 (or >100 degrees F) in the previous month (Does the participant have any of the following symptoms at the time of registration)

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
NCI Thesaurus ObjectClass
C3208
NCI Thesaurus Property
C4876
NCI Thesaurus Property-2
C3038
UMLS CUI [1]
C0476474
Unexplained weight loss over 10 percent of body weight in the previous 6 months
Description

weight loss

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
NCI Thesaurus Property
C3445
NCI Thesaurus ObjectClass
C3208
UMLS CUI [1]
C1262477
Hematopoietic Diagnosis
Description

HematopoieticDiseaseDiagnosisType

Data type

integer

Alias
NCI Thesaurus ValueDomain
C25284
NCI Thesaurus ObjectClass
C2991
NCI Thesaurus ObjectClass-2
C13324
NCI Thesaurus Property
C15220
UMLS CUI [1,1]
C0024299
UMLS CUI [1,2]
C0229601
UMLS CUI [1,3]
C0332307
If diffuse large B-cell lymphoma, specify morphologic type
Description

Morphology Type

Data type

integer

Alias
NCI Thesaurus ValueDomain
C25284
NCI Thesaurus ObjectClass
C8851
NCI Thesaurus Property
C17943
UMLS CUI [1,1]
C0079744
UMLS CUI [1,2]
C0700619
UMLS CUI [1,3]
C0332307
If Burkitt lymphoma/leukemia, specify morphologic type
Description

Morphology Type

Data type

integer

Alias
NCI Thesaurus ValueDomain
C25284
NCI Thesaurus ObjectClass
C2912
NCI Thesaurus Property
C17943
UMLS CUI [1,1]
C0006413
UMLS CUI [1,2]
C0700619
UMLS CUI [1,3]
C0332307
If Hodgkin lymphoma, specify morphologic type
Description

Morphology Type

Data type

integer

Alias
NCI Thesaurus ValueDomain
C25284
NCI Thesaurus ObjectClass
C9357
NCI Thesaurus Property
C17943
UMLS CUI [1,1]
C0019829
UMLS CUI [1,2]
C0700619
UMLS CUI [1,3]
C0332307
Date of Initial Pathologic Diagnosis
Description

CancerInitialDiagnosisDate (mm/dd/yyyy)

Data type

date

Alias
NCI Thesaurus ObjectClass
C9305
NCI Thesaurus Property
C25509
NCI Thesaurus Property-2
C15220
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25367
UMLS CUI [1,1]
C0011900
UMLS CUI [1,2]
C0024299
UMLS CUI [1,3]
C0011008
Method of Evaluation
Description

Evaluation method

Data type

integer

Alias
NCI Thesaurus ValueDomain
C25284
NCI Thesaurus ObjectClass
C20989
NCI Thesaurus Property
C16847
UMLS CUI [1]
C2911685
Other Specify
Description

Evaluation method, specify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
NCI Thesaurus ObjectClass
C20989
NCI Thesaurus Property
C16847
UMLS CUI [1]
C2911685
Is the participant >60 years of age
Description

InternationalPrognosticIndexPatientAgeAssessmentInd-2 (Please enter the information below to obtain International Prognostic Index poor risk features)

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ObjectClass-2
C20118
NCI Thesaurus Property
C20989
NCI Thesaurus Property-2
C25150
NCI Thesaurus ValueDomain
C38147
UMLS CUI [1]
C0001779
Does the participant have Stage III or IV disease
Description

InternationalPrognosticIndexPatientStageAssessmentInd-2 (Please enter the information below to obtain International Prognostic Index poor risk features)

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ObjectClass-2
C20118
NCI Thesaurus Property
C20989
NCI Thesaurus Property-2
C16899
NCI Thesaurus ValueDomain
C38147
UMLS CUI [1]
C1512894
Is the serum LDH elevated
Description

InternationalPrognosticIndexPatientLactateDehydrogenaseAssessmentInd-2 (Please enter the information below to obtain International Prognostic Index poor risk features)

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ObjectClass-2
C20118
NCI Thesaurus Property
C20989
NCI Thesaurus Property-2
C25184
NCI Thesaurus ValueDomain
C38147
UMLS CUI [1]
C0202113
Is the ECOG Performance Status 2, 3, or 4
Description

InternationalPrognosticIndexPatientPerformanceStatus2-4AssessmentInd-2 (Please enter the information below to obtain International Prognostic Index poor risk features)

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ObjectClass-2
C20118
NCI Thesaurus Property
C20989
NCI Thesaurus Property-2
C17847
NCI Thesaurus Property-3
C17848
NCI Thesaurus Property-4
C17846
NCI Thesaurus ValueDomain
C38147
UMLS CUI [1]
C1520224
Does the participant have two or more extranodal disease sites
Description

InternationalPrognosticIndexPatientExtranodalDiseaseAssessmentInd-2 (Please enter the information below to obtain International Prognostic Index poor risk features)

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ObjectClass-2
C20118
NCI Thesaurus Property
C20989
NCI Thesaurus Property-2
C2991
NCI Thesaurus Property-3
C25504
NCI Thesaurus ValueDomain
C38147
UMLS CUI [1]
C1517068
International Prognostic Index
Description

PatientInternationalPrognosticIndexScore

Data type

float

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C20118
NCI Thesaurus ValueDomain
C25338
UMLS CUI [1,1]
C1512894
UMLS CUI [1,2]
C0449820
IPI Risk Category
Description

PatientInternationalPrognosticIndexRiskCategory

Data type

integer

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C17102
NCI Thesaurus Property-2
C20118
NCI Thesaurus Property-3
C25161
NCI Thesaurus ValueDomain
C25372
UMLS CUI [1,1]
C1512894
UMLS CUI [1,2]
C0035647
Histogenetic Subtyping Markers
Description

Histogenetic Subtyping Markers

Alias
UMLS CUI-1
C0041365
UMLS CUI-2
C0017399
UMLS CUI-3
C0024299
Histogenetic Subtyping Markers
Description

TumorMarkerAvailableAssessmentType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
NCI Thesaurus Property
C20989
NCI Thesaurus ObjectClass
C17220
NCI Thesaurus Property-2
C25429
UMLS CUI [1,1]
C0024299
UMLS CUI [1,2]
C0041365
Finding Result
Description

FindingResultStatus

Data type

integer

Alias
NCI Thesaurus ObjectClass
C3367
NCI Metathesaurus Property
CL282989
NCI Thesaurus ValueDomain
C20200
NCI Thesaurus ValueDomain-2
C3367
NCI Thesaurus ValueDomain-3
C25688
UMLS CUI [1,1]
C0024299
UMLS CUI [1,2]
C0041365
UMLS CUI [1,3]
C1274040
EBV Status
Description

AntibodyEpstein-BarrVirusTestType

Data type

integer

Alias
NCI Thesaurus ValueDomain
C25284
NCI Thesaurus Property
C14204
NCI Thesaurus ObjectClass
C16295
NCI Thesaurus Property-2
C25294
UMLS CUI [1,1]
C0014644
UMLS CUI [1,2]
C0003241
UMLS CUI [1,3]
C0449438
Comments
Description

Comments

Alias
UMLS CUI-1
C0947611
UMLS CUI-2
C0024299
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]
C0024299
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Similar models

Complete this form at baseline only

1 forms
  1. StudyEvent: AMC-053 Baseline Lymphoma Disease Activity and Assessment Form (LAA)
    1. Complete this form at baseline only
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header - Baseline Lymphoma Disease Activity and Assessment Form
C0024299 (UMLS CUI-1)
C1320722 (UMLS CUI-2)
C0220825 (UMLS CUI-3)
C1332051 (UMLS CUI-4)
Visit number
Item
Visit Number
integer
C25337 (NCI Thesaurus ValueDomain)
C16696 (NCI Thesaurus ObjectClass)
C25385 (NCI Thesaurus Property)
C1549755 (UMLS CUI [1])
Item Group
Lymphoma Disease Activity and Assessment
C3869583 (UMLS CUI-1)
C0220825 (UMLS CUI-2)
C0024299 (UMLS CUI-3)
C1332051 (UMLS CUI-4)
Item
Modified Ann Arbor Stage
integer
C3208 (NCI Thesaurus ObjectClass)
C16899 (NCI Thesaurus ValueDomain)
C25161 (NCI Thesaurus Property)
C0432516 (UMLS CUI [1])
CL.1
Code List
Modified Ann Arbor Stage
CL Item
I (1)
CL Item
Ie (2)
CL Item
Ii (3)
CL Item
Iie (4)
CL Item
Iii (5)
CL Item
Iiie (6)
CL Item
Iiie+s (7)
CL Item
Iiis (8)
CL Item
Iv (9)
night sweats
Item
Recurring, drenching night sweats during the previous month
boolean
C38148 (NCI Thesaurus ValueDomain)
C3208 (NCI Thesaurus ObjectClass)
C4876 (NCI Thesaurus Property)
C36172 (NCI Thesaurus Property-2)
C0028081 (UMLS CUI [1])
persistent fever
Item
Unexplained, persistent fever >38 degrees C
boolean
C38148 (NCI Thesaurus ValueDomain)
C3208 (NCI Thesaurus ObjectClass)
C4876 (NCI Thesaurus Property)
C3038 (NCI Thesaurus Property-2)
C0476474 (UMLS CUI [1])
weight loss
Item
Unexplained weight loss over 10 percent of body weight in the previous 6 months
boolean
C38148 (NCI Thesaurus ValueDomain)
C3445 (NCI Thesaurus Property)
C3208 (NCI Thesaurus ObjectClass)
C1262477 (UMLS CUI [1])
Item
Hematopoietic Diagnosis
integer
C25284 (NCI Thesaurus ValueDomain)
C2991 (NCI Thesaurus ObjectClass)
C13324 (NCI Thesaurus ObjectClass-2)
C15220 (NCI Thesaurus Property)
C0024299 (UMLS CUI [1,1])
C0229601 (UMLS CUI [1,2])
C0332307 (UMLS CUI [1,3])
CL.5
Code List
Hematopoietic Diagnosis
CL Item
Diffuse Large B-cell Lymphoma (1)
CL Item
Burkitt Lymphoma/leukemia (2)
CL Item
Primary Effusion Lymphoma (3)
CL Item
Kshv/hhv-8+ Plasmablastic Lymphoma (lymph Node) (4)
CL Item
Plasma Lymphoma Of Oral Cavity (5)
CL Item
Polymorphic B Cell Lymphoma-ptld Type (6)
CL Item
Hodgkin's Lymphoma (7)
CL Item
Other (8)
Item
If diffuse large B-cell lymphoma, specify morphologic type
integer
C25284 (NCI Thesaurus ValueDomain)
C8851 (NCI Thesaurus ObjectClass)
C17943 (NCI Thesaurus Property)
C0079744 (UMLS CUI [1,1])
C0700619 (UMLS CUI [1,2])
C0332307 (UMLS CUI [1,3])
CL.6
Code List
If diffuse large B-cell lymphoma, specify morphologic type
CL Item
Centroblastic (1)
CL Item
Immunoblastic (2)
CL Item
Not Specified (3)
CL Item
Other (4)
Item
If Burkitt lymphoma/leukemia, specify morphologic type
integer
C25284 (NCI Thesaurus ValueDomain)
C2912 (NCI Thesaurus ObjectClass)
C17943 (NCI Thesaurus Property)
C0006413 (UMLS CUI [1,1])
C0700619 (UMLS CUI [1,2])
C0332307 (UMLS CUI [1,3])
CL.7
Code List
If Burkitt lymphoma/leukemia, specify morphologic type
CL Item
Classical (1)
CL Item
Plasmacytoid (2)
CL Item
B Cell Lymphoma Unclassifiable, W/features Intermediate Between Dlbcl And Burkitt's. (atypical) (3)
CL Item
Other (4)
Item
If Hodgkin lymphoma, specify morphologic type
integer
C25284 (NCI Thesaurus ValueDomain)
C9357 (NCI Thesaurus ObjectClass)
C17943 (NCI Thesaurus Property)
C0019829 (UMLS CUI [1,1])
C0700619 (UMLS CUI [1,2])
C0332307 (UMLS CUI [1,3])
CL.8
Code List
If Hodgkin lymphoma, specify morphologic type
CL Item
Mixed Cellularity (1)
CL Item
Nodular Sclerosis (2)
CL Item
Lymphocyte Rich (3)
CL Item
Lymphocyte Depleted (4)
CL Item
Unclassified (5)
Date of Initial Pathologic Diagnosis
Item
Date of Initial Pathologic Diagnosis
date
C9305 (NCI Thesaurus ObjectClass)
C25509 (NCI Thesaurus Property)
C15220 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
C0011900 (UMLS CUI [1,1])
C0024299 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
Item
Method of Evaluation
integer
C25284 (NCI Thesaurus ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C16847 (NCI Thesaurus Property)
C2911685 (UMLS CUI [1])
CL.9
Code List
Method of Evaluation
CL Item
Cytology (1)
CL Item
Biopsy (2)
CL Item
Other (3)
Evaluation method, specify
Item
Other Specify
text
C25685 (NCI Thesaurus ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C16847 (NCI Thesaurus Property)
C2911685 (UMLS CUI [1])
Is the participant >60 years of age
Item
Is the participant >60 years of age
boolean
C16960 (NCI Thesaurus ObjectClass)
C20118 (NCI Thesaurus ObjectClass-2)
C20989 (NCI Thesaurus Property)
C25150 (NCI Thesaurus Property-2)
C38147 (NCI Thesaurus ValueDomain)
C0001779 (UMLS CUI [1])
International Prognostic Index Patient Stage
Item
Does the participant have Stage III or IV disease
boolean
C16960 (NCI Thesaurus ObjectClass)
C20118 (NCI Thesaurus ObjectClass-2)
C20989 (NCI Thesaurus Property)
C16899 (NCI Thesaurus Property-2)
C38147 (NCI Thesaurus ValueDomain)
C1512894 (UMLS CUI [1])
serum LDH
Item
Is the serum LDH elevated
boolean
C16960 (NCI Thesaurus ObjectClass)
C20118 (NCI Thesaurus ObjectClass-2)
C20989 (NCI Thesaurus Property)
C25184 (NCI Thesaurus Property-2)
C38147 (NCI Thesaurus ValueDomain)
C0202113 (UMLS CUI [1])
ECOG Performance Status
Item
Is the ECOG Performance Status 2, 3, or 4
boolean
C16960 (NCI Thesaurus ObjectClass)
C20118 (NCI Thesaurus ObjectClass-2)
C20989 (NCI Thesaurus Property)
C17847 (NCI Thesaurus Property-2)
C17848 (NCI Thesaurus Property-3)
C17846 (NCI Thesaurus Property-4)
C38147 (NCI Thesaurus ValueDomain)
C1520224 (UMLS CUI [1])
extranodal disease sites
Item
Does the participant have two or more extranodal disease sites
boolean
C16960 (NCI Thesaurus ObjectClass)
C20118 (NCI Thesaurus ObjectClass-2)
C20989 (NCI Thesaurus Property)
C2991 (NCI Thesaurus Property-2)
C25504 (NCI Thesaurus Property-3)
C38147 (NCI Thesaurus ValueDomain)
C1517068 (UMLS CUI [1])
PatientInternationalPrognosticIndexScore
Item
International Prognostic Index
float
C16960 (NCI Thesaurus ObjectClass)
C20118 (NCI Thesaurus Property)
C25338 (NCI Thesaurus ValueDomain)
C1512894 (UMLS CUI [1,1])
C0449820 (UMLS CUI [1,2])
Item
IPI Risk Category
integer
C16960 (NCI Thesaurus ObjectClass)
C17102 (NCI Thesaurus Property)
C20118 (NCI Thesaurus Property-2)
C25161 (NCI Thesaurus Property-3)
C25372 (NCI Thesaurus ValueDomain)
C1512894 (UMLS CUI [1,1])
C0035647 (UMLS CUI [1,2])
CL.16
Code List
IPI Risk Category
CL Item
Low Risk (1)
CL Item
Low-intermediate Risk (2)
CL Item
High-intermediate Risk (3)
CL Item
High Risk (4)
Item Group
Histogenetic Subtyping Markers
C0041365 (UMLS CUI-1)
C0017399 (UMLS CUI-2)
C0024299 (UMLS CUI-3)
Item
Histogenetic Subtyping Markers
text
C25284 (NCI Thesaurus ValueDomain)
C20989 (NCI Thesaurus Property)
C17220 (NCI Thesaurus ObjectClass)
C25429 (NCI Thesaurus Property-2)
C0024299 (UMLS CUI [1,1])
C0041365 (UMLS CUI [1,2])
CL.17
Code List
Histogenetic Subtyping Markers
CL Item
Cd10 (1)
CL Item
Bcl6 (2)
CL Item
Mum1 (3)
CL Item
Foxp1 (4)
CL Item
Gcet1 (5)
Item
Finding Result
integer
C3367 (NCI Thesaurus ObjectClass)
CL282989 (NCI Metathesaurus Property)
C20200 (NCI Thesaurus ValueDomain)
C3367 (NCI Thesaurus ValueDomain-2)
C25688 (NCI Thesaurus ValueDomain-3)
C0024299 (UMLS CUI [1,1])
C0041365 (UMLS CUI [1,2])
C1274040 (UMLS CUI [1,3])
CL.18
Code List
Finding Result
CL Item
Positive (1)
CL Item
Negative (2)
CL Item
Not Assessed (3)
Item
EBV Status
integer
C25284 (NCI Thesaurus ValueDomain)
C14204 (NCI Thesaurus Property)
C16295 (NCI Thesaurus ObjectClass)
C25294 (NCI Thesaurus Property-2)
C0014644 (UMLS CUI [1,1])
C0003241 (UMLS CUI [1,2])
C0449438 (UMLS CUI [1,3])
CL.19
Code List
EBV Status
CL Item
Eber Negative (1)
CL Item
Eber Positive (2)
CL Item
Not Done (3)
Item Group
Comments
C0947611 (UMLS CUI-1)
C0024299 (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])
C0024299 (UMLS CUI [1,2])
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