ID

2961

Beskrivning

Primary Brain Cancer - On-Study Form Newly Diagnosed Patients Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=E51E77B9-7E48-3A03-E034-0003BA3F9857

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=E51E77B9-7E48-3A03-E034-0003BA3F9857

Nyckelord

Uppladdad den

19 september 2012

DOI

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Licens

Creative Commons BY-NC 3.0 Legacy

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On-Study - Primary Brain Cancer - On-Study Form Newly Diagnosed Patients - 2293729v3.0

model
Detaljer

No Instruction available.

1 Formulär

StudyEvent: Primary Brain Cancer - On-Study Form Newly Diagnosed Patients
1. No Instruction available.

Name

Typ

Description | Question | Decode (Coded Value)

Datatyp

Alias

CRF Header

Item Group

Crf Header

ProtocolCoordinatingIdentifierNumber

Item

Coordinating Group Protocol No.

text

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25462 (NCI Thesaurus Property)
C0700114 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)

CoordinatingGroupIdentifierCode

Item

Coordinating Group Code

text

C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25462 (NCI Thesaurus ObjectClass)
C0700114 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)

ProtocolTitleName

Item

Protocol Title

text

C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C42774 (NCI Thesaurus Property)
C1705823 (UMLS 2011AA Property)

PatientCoordinatingIdentifierNumber

Item

Patient Study ID

text

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25462 (NCI Thesaurus Property)
C0700114 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)

CombinedInstitutionName

Item

Institution/Affiliate

text

C25454 (NCI Thesaurus ObjectClass)
C0205195 (UMLS 2011AA ObjectClass)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ValueDomain)
C0018704 (UMLS 2011AA ValueDomain)

PatientParticipatingIdentifierNumber

Item

Other Patient ID

text

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)

ParticipatingGroupIdentifierCode

Item

Participating Group Code

text

C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C25608 (NCI Thesaurus ObjectClass)
C0679823 (UMLS 2011AA ObjectClass)
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)

PatientName

Item

Patient Name (initials acceptable)

text

C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)

Brain: Form Administration

Item Group

Brain: Form Administration

ResponsiblePersonName

Item

Person Completing Form

text

C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25657 (NCI Thesaurus ObjectClass)
C1273518 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)

DataAmendedInd-3

Item

Are data amended (If data are amended, please circle in red when using paper form)

text

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)

CL.1

Code List

Are data amended (If data are amended, please circle in red when using paper form)

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

CL Item

No (No)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

Brain: Disease Description

Item Group

Brain: Disease Description

FirstBiopsyPositiveDate

Item

Date of Initial Diagnosis of Primary Tumor (MM DD YYYY)

date

C15189 (NCI Thesaurus ObjectClass)
C0005558 (UMLS 2011AA ObjectClass)
C25509 (NCI Thesaurus ObjectClass)
C1279901 (UMLS 2011AA ObjectClass)
C25246 (NCI Thesaurus Property)
C1446409 (UMLS 2011AA Property)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain)

DiagnosisMethodType

Item

Basis of Diagnosis

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C16847 (NCI Thesaurus Property)
C0449851 (UMLS 2011AA Property)
C15220 (NCI Thesaurus ObjectClass)
C0011900 (UMLS 2011AA ObjectClass)

CL.2

Code List

Basis of Diagnosis

CL Item

Histology (Histology)

C16681 (NCI Thesaurus)
C0019638 (UMLS 2011AA)
C16681 (NCI Thesaurus)
C0019638 (UMLS 2011AA)

CL Item

Imaging Only (Imaging only)

BrainInfratentorialInvolvementInd-3

Item

Infratentorial Involvement

text

C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C12439 (NCI Thesaurus ObjectClass)
C0006104 (UMLS 2011AA ObjectClass)
C25548 (NCI Thesaurus Property)
C1314939 (UMLS 2011AA Property)
CL211504 (NCI Metathesaurus Property)

CL.3

Code List

Infratentorial Involvement

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

CL Item

No (No)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

SupratentorialInvolvementInd-3

Item

Supratentorial Involvement

text

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25548 (NCI Thesaurus Property)
C1314939 (UMLS 2011AA Property)
C12923 (NCI Thesaurus ObjectClass)
C0441938 (UMLS 2011AA ObjectClass)

CL.4

Code List

Supratentorial Involvement

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

CL Item

No (No)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

BrainLesionSite

Item

Site of Lesion (check all that apply)

text

C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)
C3824 (NCI Thesaurus ObjectClass)
C0221198 (UMLS 2011AA ObjectClass)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C12439 (NCI Thesaurus ObjectClass)
C0006104 (UMLS 2011AA ObjectClass)

CL.5

Code List

Site of Lesion (check all that apply)

CL Item

Frontal Lobe (Frontal)

C12352 (NCI Thesaurus)
C0016733 (UMLS 2011AA)

CL Item

Temporal Lobe (Temporal)

C12353 (NCI Thesaurus)
C0039485 (UMLS 2011AA)

CL Item

Parietal Lobe (Parietal)

C12354 (NCI Thesaurus)
C0030560 (UMLS 2011AA)

CL Item

Occipital Lobe (Occipital)

C12355 (NCI Thesaurus)
C0028785 (UMLS 2011AA)

CL Item

Cerebellum (Cerebellum)

C12445 (NCI Thesaurus)
C0007765 (UMLS 2011AA)

CL Item

Cerebellar Peduncle (Cerebellar peduncle)

C0228515 (NCI Metathesaurus)

CL Item

Cerebellar Hemisphere (Cerebellar hemisphere)

C0228465 (NCI Metathesaurus)

CL Item

Cerebellar Vermis (Cerebellar vermis)

CL Item

Brainstem (Brainstem)

CL Item

Midbrain (Midbrain)

C0025462 (NCI Metathesaurus)

CL Item

Pons (Pons)

C0032639 (NCI Metathesaurus)

CL Item

Medulla (Medulla)

CL Item

Dorsal Exophytic Brainstem (Dorsal exophytic brainstem)

CL Item

Spinal Cord (c1 And Below) (Spinal cord)

CL Item

Corpus Callosum (Corpus callosum)

C12446 (NCI Thesaurus)
C0010090 (UMLS 2011AA)

CL Item

Optic Chiasm (Optic chiasm)

C0029126 (NCI Metathesaurus)

CL Item

Hypothalamus (Hypothalamus)

C12458 (NCI Thesaurus)
C0020663 (UMLS 2011AA)

CL Item

Cavernous Sinus (Cavernous sinus)

C12690 (NCI Thesaurus)
C0007473 (UMLS 2011AA)

CL Item

Lateral Ventricle (Lateral ventricle)

C12834 (NCI Thesaurus)
C0152279 (UMLS 2011AA)

CL Item

Third Ventricle (Third ventricle)

C12827 (NCI Thesaurus)
C0149555 (UMLS 2011AA)

CL Item

Fourth Ventricle (Fourth ventricle)

C12828 (NCI Thesaurus)
C0149556 (UMLS 2011AA)

CL Item

Cisterna Magna (Cisterna magna)

C32324 (NCI Thesaurus)
C0008841 (UMLS 2011AA)

CL Item

Basal Ganglia (Basal ganglia)

C12447 (NCI Thesaurus)
C0004781 (UMLS 2011AA)

CL Item

Thalamus (Thalamus)

C12459 (NCI Thesaurus)
C0039729 (UMLS 2011AA)

CL Item

Optic Nerve (Optic nerve)

C12761 (NCI Thesaurus)
C0029130 (UMLS 2011AA)

CL Item

Pineal (Pineal)

CL Item

Aqueduct Of Sylvius (Aqueduct of sylvius)

C32135 (NCI Thesaurus)
C0007769 (UMLS 2011AA)

CL Item

Leptomeningeal (Leptomeningeal)

CL Item

Cervical (Cervical)

C12844 (NCI Thesaurus)
C0205064 (UMLS 2011AA)

CL Item

Thoracic (Thoracic)

C13360 (NCI Thesaurus)
C0817096 (UMLS 2011AA)

CL Item

Lumbar (Lumbar)

CL Item

Conus (Conus)

C0598489 (NCI Metathesaurus)

CL Item

Cauda Equina (Cauda equina)

C12689 (NCI Thesaurus)
C0007458 (UMLS 2011AA)

CL Item

Other, Specify (Other specify)

PrimaryDiseaseSiteSpecify

Item

Other specify

text

C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C25251 (NCI Thesaurus ObjectClass)
C0205225 (UMLS 2011AA ObjectClass)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)

BrainTumorSideType

Item

Side

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C12439 (NCI Thesaurus ObjectClass)
C0006104 (UMLS 2011AA ObjectClass)
C25306 (NCI Thesaurus Property)
C0441987 (UMLS 2011AA Property)

CL.6

Code List

Side

CL Item

Left (Left)

C25229 (NCI Thesaurus)
C0205091 (UMLS 2011AA)

CL Item

Right (Right)

C25228 (NCI Thesaurus)
C0205090 (UMLS 2011AA)

CL Item

Both (Both)

C49636 (NCI Thesaurus)
C1706086 (UMLS 2011AA)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

BrainTumorHistologicCategory

Item

Histologic Type

text

C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C12439 (NCI Thesaurus ObjectClass)
C0006104 (UMLS 2011AA ObjectClass)
C25526 (NCI Thesaurus Property)
C0205462 (UMLS 2011AA Property)
C25161 (NCI Thesaurus Property)
C0008902 (UMLS 2011AA Property)
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)

CL.7

Code List

Histologic Type

CL Item

Diffuse Astrocytoma (Diffuse astrocytoma)

C7173 (NCI Thesaurus)
C0280785 (UMLS 2011AA)

CL Item

9420-3 Fibrillary Astrocytoma (c71._) (Fibrillary astrocytoma)

CL Item

9410-3 Protoplasmic Astrocytoma (c71._) (Protoplasmic astrocytoma)

CL Item

9411-3 Gemistocytic Astrocytoma (c71._) (Gemistocytic astrocytoma)

CL Item

9401-3 Astrocytoma, Anaplastic (c71._) (Anaplastic astrocytoma)

CL Item

9440-3 Glioblastoma, Nos (c71._) (Glioblastoma)

CL Item

9441-3 Giant Cell Glioblastoma (c71._) (Giant cell glioblastoma)

CL Item

9442-3 Gliosarcoma (c71._) (Gliosarcoma)

CL Item

9421-1 Pilocytic Astrocytoma (c71._) (Pilocytic astrocytoma)

CL Item

9424-3 Pleomorphic Xanthoastrocytoma (c71._) (Pleomorphic xanthoastrocytoma)

CL Item

9384-1 Subependymal Giant Cell Astrocytoma (c71._) (Subependymal giant cell astrocytoma)

CL Item

9450-3 Oligodendroglioma, Nos (c71._) (Oligodendroglioma)

CL Item

9451-3 Oligodendroglioma, Anaplastic (c71._) (Anaplastic oligodendroglioma)

CL Item

Oligoastrocytoma (Oligoastrocytoma)

CL Item

Anaplastic Oligoastrocytoma (Anaplastic oligoastrocytoma)

C6959 (NCI Thesaurus)
C0431108 (UMLS 2011AA)

CL Item

9391-3 Ependymoma, Nos (c71._) (Ependymoma)

CL Item

9392-3 Ependymoma, Anaplastic (c71._) (Anaplastic ependymoma)

CL Item

9394-1 Myxopapillary Ependymoma (c72.0) (Myxopapillary ependymoma)

CL Item

9383-1 Subependymoma (c71._) (Subependymoma)

CL Item

9390-0 Choroid Plexus Papilloma, Nos (c71.5) (Choroid plexus papilloma)

CL Item

9390-3 Choroid Plexus Carcinoma (c71.5) (Choroid plexus carcinoma)

CL Item

9430-3 Astroblastoma (c71._) (Astroblastoma)

CL Item

9381-3 Gliomatosis Cerebri (c71._) (Gliomatosis cerebri)

CL Item

Chordoid Glioma Of The Third Ventricle (Chordoid glioma of the third ventricle)

C6961 (NCI Thesaurus)
C1322252 (UMLS 2011AA)

CL Item

9492-0 Gangliocytoma (Gangliocytoma)

CL Item

9493-0 Dysplastic Gangliocytoma Of Cerebellum (lhermitte-duclos) (c71.6) (Dysplastic gangliocytoma of cerebellum)

CL Item

Desmoplastic Infantile Astrocytoma/ganglioma (Desmoplastic infantile astrocytoma/ganglioma)

CL Item

Low Grade Astrocytoma, Nos (Low grade astrocytoma NOS)

CL Item

9413-0 Dysembryoplastic Neuroepithelial Tumor (Dysembryoplastic neuroepithelial tumor)

CL Item

9505-1 Ganglioglioma, Nos (Ganglioglioma)

CL Item

9505-3 Ganglioglioma, Anaplastic (Anaplastic ganglioglioma)

CL Item

9506-1 Central Neurocytoma (Central neurocytoma)

CL Item

Cerebellar Liponeurocytoma (Cerebellar liponeurocytoma)

C6905 (NCI Thesaurus)
C1370507 (UMLS 2011AA)

CL Item

Paraganglioma Of The Filum Terminale (Paraganglioma of the filum terminale)

CL Item

9522-3 Olfactory Neuroblastoma (c30.0) (Olfactory neuroblastoma)

CL Item

9523-3 Olfactory Neuroepithelioma (c30.0) (Olfactory neuroepithelioma)

CL Item

Neuroblastomas Of The Adrenal Gland And Sympathetic Nervous System (Neuroblastomas of the adrenal gland and sympathetic nervous system)

CL Item

9361-1 Pineocytoma (c75.3) (Pineocytoma)

CL Item

9362-3 Pineoblastoma (c75.3) (Pineoblastoma)

CL Item

Pineal Parenchymal Tumor Of Indeterminate Differentiation (Pineal parenchymal tumor of indeterminate differentiation)

CL Item

9501-3 Medulloepithelioma, Nos (Medulloepithelioma)

CL Item

Ependymoblastoma (Ependymoblastoma)

C4915 (NCI Thesaurus)
C0700367 (UMLS 2011AA)

CL Item

9470-3 Medulloblastoma, Nos (c71.6) (Medulloblastoma)

CL Item

Desmoplastic Medulloblastoma (Desmoplastic medulloblastoma)

C4956 (NCI Thesaurus)
C0751291 (UMLS 2011AA)

CL Item

9474-3 Large Cell Medulloblastoma (c71.6) (Large cell medulloblastoma)

CL Item

9472-3 Medullomyoblastoma (c71.6) (Medullomyoblastoma)

CL Item

Melanotic Medulloblastoma (Melanotic medulloblastoma)

C9497 (NCI Thesaurus)
C1275668 (UMLS 2011AA)

CL Item

Supratentorial Primitive Neuroectodermal Tumor (pnet) (Supratentorial primitive neuroectodermal tumor)

CL Item

9500-3 Neuroblastoma, Nos (Neuroblastoma)

CL Item

9490-3 Ganglioneuroblastoma (Ganglioneuroblastoma)

CL Item

9508-3 Atypical Teratoid-rhabdoid Tumor (c71._) (Atypical teratoid/rhabdoid tumor)

CL Item

Schwannoma (neurilemmoma, Neurinoma) (Schwannoma)

CL Item

High Grade Astrocytoma, Nos (High grade astrocytoma NOS)

CL Item

9064-3 Germinoma (Germinoma)

CL Item

Embryonal Carcinoma (Embryonal carcinoma)

C3752 (NCI Thesaurus)
C0026705 (UMLS 2011AA)

CL Item

Yolk Sac Tumor (Yolk sac tumor)

C3011 (NCI Thesaurus)
C0014145 (UMLS 2011AA)

CL Item

Choriocarcinoma (Choriocarcinoma)

C2948 (NCI Thesaurus)
C0008497 (UMLS 2011AA)

CL Item

Teratoma (Teratoma)

C3403 (NCI Thesaurus)
C0039538 (UMLS 2011AA)

CL Item

Mixed Germ Cell Tumor (Mixed germ cell tumors)

C4285 (NCI Thesaurus)

CL Item

9350-1 Craniopharyngioma (c75.2) (Craniopharyngioma)

CL Item

9351-1 Craniopharyngioma, Adamantinomatous (c75.2) (Adamantinomatous)

CL Item

9352-1 Craniopharyngioma, Papillary (c75.2) (Papillary)

CL Item

9580-0 Granular Cell Tumor, Nos (Granular cell tumor)

CL Item

9531-0 Meningothelial Meningioma (Meningothelial meningioma)

CL Item

9532-0 Fibrous Meningioma (Fibrous meningioma)

CL Item

9537-0 Transitional Meningioma (Transitional meningioma)

CL Item

9533-0 Psammomatous Meningioma (Psammomatous meningioma)

CL Item

9534-0 Angiomatous Meningioma (Angiomatous meningioma)

CL Item

Microcystic Meningioma (Microcystic meningioma)

CL Item

Secretory Meningioma (Secretory meningioma)

CL Item

Lymphoplasmacyte-rich Meningioma (Lymphoplasmacyte-rich meningioma)

CL Item

Metaplastic Meningioma (Metaplastic meningioma)

CL Item

9539-1 Atypical Meningioma (Atypical meningioma)

CL Item

9538-1 Clear Cell Meningioma (Clear cell meningioma)

CL Item

Chordoid Meningioma (Chordoid meningioma)

CL Item

Rhabdoid Meningioma (Rhabdoid meningioma)

CL Item

9538-3 Papillary Meningioma (Papillary meningioma)

CL Item

Anaplastic Meningioma (Anaplastic meningioma)

CL Item

Other, Specify (Other specify)

TumorHistologicCategorySpecify

Item

Other specify

text

C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C25526 (NCI Thesaurus Property)
C0205462 (UMLS 2011AA Property)
C25161 (NCI Thesaurus Property)
C0008902 (UMLS 2011AA Property)

BrainTumorWHOHistologicGrade

Item

Histologic Grade (WHO)

text

C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C12439 (NCI Thesaurus ObjectClass)
C0006104 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
C0043237 (NCI Metathesaurus Property)
C25526 (NCI Thesaurus ValueDomain)
C0205462 (UMLS 2011AA ValueDomain)
C18000 (NCI Thesaurus ValueDomain)
C0919553 (UMLS 2011AA ValueDomain)

CL.8

Code List

Histologic Grade (WHO)

CL Item

Well Differentiated (grade I) (Well differentiated (Grade I))

CL Item

Moderately Differentiated (grade Ii) (Moderately Differentiated (Grade II))

CL Item

Poorly Differentiated (grade Iii) (Poorly Differentiated (Grade III))

CL Item

Undifferentiated (grade Iv) (Undifferentiated (Grade IV))

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

CerebrospinalFluidCytologyPerformedInd

Item

CSF Cytology

text

C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C16491 (NCI Thesaurus ObjectClass)
C0010819 (UMLS 2011AA ObjectClass)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C12692 (NCI Thesaurus ObjectClass)
C0007806 (UMLS 2011AA ObjectClass)

CL.9

Code List

CSF Cytology

CL Item

Positive (Positive)

C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)

CL Item

Negative (Negative)

C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)

CL Item

Undetermined (Undetermined)

CL Item

Not Done (Not Done)

CL281691 (NCI Metathesaurus)

CerebrospinalFluidInvolvementInd

Item

CSF Involvement

text

C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C12692 (NCI Thesaurus ObjectClass)
C0007806 (UMLS 2011AA ObjectClass)
C25548 (NCI Thesaurus Property)
C1314939 (UMLS 2011AA Property)

CL.10

Code List

CSF Involvement

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

CL Item

No (No)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

Brain: Neurologic Function

Item Group

Brain: Neurologic Function

NeurologicalFunctionStatus

Item

Neurologic Function Status

text

C25262 (NCI Thesaurus ObjectClass)
C0205494 (UMLS 2011AA ObjectClass)
C25518 (NCI Thesaurus ObjectClass)
C0542341 (UMLS 2011AA ObjectClass)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)

CL.11

Code List

Neurologic Function Status

CL Item

No Neurologic Symptoms, Fully Active At Home/work Without Assistance (No neurologic symptoms, fully active at home/work without assistance)

CL Item

Minor Neurologic Symptoms, Fully Active At Home/work Without Assistance (Minor neurologic symptoms, fully active at home/work without assistance)

CL Item

Moderate Neurologic Symptoms, Fully Active At Home/work But Requires Assistance (Moderate neurologic symptoms, fully active at home/work but requires assistance)

CL Item

Moderate Neurologic Symptoms, Less Than Fully Active At Home/work And Requires Assitance (Moderate neurologic symptoms, less than fully active at home/work and requires assistance)

CL Item

Severe Neurologic Symptoms, Totally Inactive Requiring Complete Assistance At Home Or Institution, Unable To Work (Severe neurologic symptoms, totally inactive requiring complete assistance at home or institution, unable to work)

Brain: Prior Health History

Item Group

Brain: Prior Health History

IntracranialBrainHemorrhageOccurrenceInd-3

Item

Has the patient experienced an intracranial hemorrhage?

text

C12439 (NCI Thesaurus ObjectClass)
C0006104 (UMLS 2011AA ObjectClass)
C38236 (NCI Thesaurus ObjectClass)
C1522213 (UMLS 2011AA ObjectClass)
C26791 (NCI Thesaurus Property)
C0019080 (UMLS 2011AA Property)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)

CL.12

Code List

Has the patient experienced an intracranial hemorrhage?

CL Item

No (No)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

BrainHemorrhageObservedMostRecentDate

Item

Date of Most Recent (MM DD YYYY)

date

C12439 (NCI Thesaurus ObjectClass)
C0006104 (UMLS 2011AA ObjectClass)
C26791 (NCI Thesaurus Property)
C0019080 (UMLS 2011AA Property)
C25599 (NCI Thesaurus Property)
C1441672 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25577 (NCI Thesaurus ValueDomain)
C1513491 (UMLS 2011AA ValueDomain)

EyeHemorrhageOccurrenceInd-3

Item

Has the patient experienced an intraocular hemorrhage?

text

C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C26791 (NCI Thesaurus Property)
C0019080 (UMLS 2011AA Property)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C0015392 (NCI Metathesaurus ObjectClass)

CL.13

Code List

Has the patient experienced an intraocular hemorrhage?

CL Item

No (No)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

EyeHemorrhageObservedMostRecentDate

Item

Date of Most Recent (MM DD YYYY)

date

C0015392 (NCI Metathesaurus ObjectClass)
C26791 (NCI Thesaurus Property)
C0019080 (UMLS 2011AA Property)
C25599 (NCI Thesaurus Property)
C1441672 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25577 (NCI Thesaurus ValueDomain)
C1513491 (UMLS 2011AA ValueDomain)

PatientMedicalConditionCurrentType

Item

Current Medical Conditions (currently symptomatic or on medications for)

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25261 (NCI Thesaurus Property)
C0205476 (UMLS 2011AA Property)
C25457 (NCI Thesaurus Property)
C0348080 (UMLS 2011AA Property)

CL.14

Code List

Current Medical Conditions (currently symptomatic or on medications for)

CL Item

Cerebrovascular Disease (Cerebrovascular disease)

CL Item

Cardiac Disease (Cardiac disease)

CL Item

Deep Vein Thrombosis (Deep vein thrombosis)

CL Item

Hypertension (Hypertension)

C3117 (NCI Thesaurus)
C0020538 (UMLS 2011AA)

CL Item

Diabetes (Diabetes)

CL Item

Other Malignancies, Specify (Other malignancies specify)

CL Item

Other, Specify (Other specify)

MalignantDiseaseOtherPresentSpecify

Item

Other malignancies specify

text

C14143 (NCI Thesaurus ObjectClass)
C0205282 (UMLS 2011AA ObjectClass)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C17649 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA Property)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)

PatientMedicalConditionCurrentSpecify

Item

Other specify

text

C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25261 (NCI Thesaurus Property)
C0205476 (UMLS 2011AA Property)
C25457 (NCI Thesaurus Property)
C0348080 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25471 (NCI Thesaurus ValueDomain)
C0521116 (UMLS 2011AA ValueDomain)

Brain: Concomitant Medications

Item Group

Brain: Concomitant Medications

AnticonvulsantMedicationAdministrationInd-3

Item

Is the person receiving anti-convulsant medication?

text

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C459 (NCI Thesaurus ObjectClass)
C0013227 (UMLS 2011AA ObjectClass)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)
C264 (NCI Thesaurus ObjectClass)
C0003286 (UMLS 2011AA ObjectClass)

CL.15

Code List

Is the person receiving anti-convulsant medication?

CL Item

No (No)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

AnticonvulsantMedicationEnzymePresentInd-3

Item

Is this anti-convulsant medication enzyme-inducing?

text

C459 (NCI Thesaurus ObjectClass)
C0013227 (UMLS 2011AA ObjectClass)
C264 (NCI Thesaurus ObjectClass)
C0003286 (UMLS 2011AA ObjectClass)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C16554 (NCI Thesaurus Property)
C0014442 (UMLS 2011AA Property)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)

CL.16

Code List

Is this anti-convulsant medication enzyme-inducing?

CL Item

No (No)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

CorticosteroidAdministrationInd-3

Item

Is the patient receiving corticosteroids?

text

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25629 (NCI Thesaurus Property)
C0332152 (UMLS 2011AA Property)
C2322 (NCI Thesaurus ObjectClass)
C0001617 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)

CL.17

Code List

Is the patient receiving corticosteroids?

CL Item

No (No)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

AgentCourseTotalDose

Item

Agent Total Dose (per day)

double

C25304 (NCI Thesaurus ValueDomain)
C0439810 (UMLS 2011AA ValueDomain)
C25379 (NCI Thesaurus Property)
C0750729 (UMLS 2011AA Property)
C25488 (NCI Thesaurus ValueDomain)
C0178602 (UMLS 2011AA ValueDomain)
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)

OtherMedicationAdministrationInd-3

Item

Is the patient receiving other medications?

text

C17649 (NCI Thesaurus ObjectClass)
C0205394 (UMLS 2011AA ObjectClass)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C459 (NCI Thesaurus ObjectClass)
C0013227 (UMLS 2011AA ObjectClass)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)

CL.18

Code List

Is the patient receiving other medications?

CL Item

No (No)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

AgentName

Item

Agent Name (If Yes,)

text

C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C1708 (NCI Thesaurus ValueDomain)
C0450442 (UMLS 2011AA ValueDomain)
C42614 (NCI Thesaurus ValueDomain)
C0027365 (UMLS 2011AA ValueDomain)

AgentName

Item

Agent Name (If Yes,)

text

AgentName

Item

Agent Name (If Yes,)

text

AgentBeginDate

Item

Agent Start Date (MM DD YYYY)

date

C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25431 (NCI Thesaurus ValueDomain)
C0439659 (UMLS 2011AA ValueDomain)
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)

AgentBeginDate

Item

Agent Start Date (MM DD YYYY)

date

AgentBeginDate

Item

Agent Start Date (MM DD YYYY)

date

Brain: Prior Surgical Treatment for Primary Site

Item Group

Brain: Prior Surgical Treatment For Primary Site

PrimarySurgeryDate

Item

Primary Surgery Date (MM DD YYYY)

date

C25251 (NCI Thesaurus ObjectClass)
C0205225 (UMLS 2011AA ObjectClass)
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain)

BrainMalignantNeoplasmExtentSurgicalResectionType

Item

Extent of Resection (at primary site)

text

C12439 (NCI Thesaurus ObjectClass)
C0006104 (UMLS 2011AA ObjectClass)
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
C25698 (NCI Thesaurus Property)
C15232 (NCI Thesaurus Property)
C0728940 (UMLS 2011AA Property)
C25332 (NCI Thesaurus Property)
C0439792 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)

CL.19

Code List

Extent of Resection (at primary site)

CL Item

Biopsy (Biopsy)

C15189 (NCI Thesaurus)
C0005558 (UMLS 2011AA)

CL Item

Subtotal (Subtotal)

CL Item

Total (gross) (Total (gross))

ResidualDiseasePositiveContrastInd

Item

Enhancing residual disease?

text

C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C37895 (NCI Thesaurus ObjectClass)
C1609982 (UMLS 2011AA ObjectClass)
C25246 (NCI Thesaurus Property)
C1446409 (UMLS 2011AA Property)
C390 (NCI Thesaurus Property)
C0009924 (UMLS 2011AA Property)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)

CL.20

Code List

Enhancing residual disease?

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

CL Item

No (No)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

CL Item

Indeterminate (Indeterminate)

C48658 (NCI Thesaurus)
C0205258 (UMLS 2011AA)

ResidualDiseaseNegativeContrastInd

Item

Non-enhancing residual disease?

text

C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C37895 (NCI Thesaurus ObjectClass)
C1609982 (UMLS 2011AA ObjectClass)
C25247 (NCI Thesaurus Property)
C0205160 (UMLS 2011AA Property)
C390 (NCI Thesaurus Property)
C0009924 (UMLS 2011AA Property)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)

CL.21

Code List

Non-enhancing residual disease?

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

CL Item

No (No)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

CL Item

Indeterminate (Indeterminate)

C48658 (NCI Thesaurus)
C0205258 (UMLS 2011AA)

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On-Study - Primary Brain Cancer - On-Study Form Newly Diagnosed Patients - 2293729v3.0

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