ID

3119

Descrição

CALGB: Imaging Form Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=46848A6F-07AE-238A-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=46848A6F-07AE-238A-E044-0003BA3F9857

Palavras-chave

Transferido a

19 de setembro de 2012

DOI

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Licença

Creative Commons BY-NC 3.0 Legacy

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On-Study - CALGB: Imaging Form - 2730039v1.0

model
Detalhes

Instructions: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice...

1 Formulários

StudyEvent: CALGB: Imaging Form
1. Instructions: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice...

Name

Tipo

Description | Question | Decode (Coded Value)

Tipo de dados

Alias

Unnamed1

Item Group

Unnamed1

CALGBFormIdentifierNumber

Item

CALGB Form

text

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C19464 (NCI Thesaurus ObjectClass)
C0376315 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25442 (NCI Thesaurus ObjectClass)
C1516238 (UMLS 2011AA ObjectClass)

ProtocolCALGBIdentifierNumber

Item

CALGB Study No

text

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25442 (NCI Thesaurus Property)
C1516238 (UMLS 2011AA Property)

PatientCALGBIdentifierNumber

Item

CALGB Patient ID

text

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25442 (NCI Thesaurus Property)
C1516238 (UMLS 2011AA Property)

DiagnosticComputedTomographyPerformedDate

Item

Date of CT Scan

date

C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C17204 (NCI Thesaurus ObjectClass)
C0040405 (UMLS 2011AA ObjectClass)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C25482 (NCI Thesaurus ObjectClass)
C0348026 (UMLS 2011AA ObjectClass)

DataAmendedInd-3

Item

Are data amended

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

CL Item

Yes (Yes)

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

Unnamed2

Item Group

Unnamed2

PatientInitialsName

Item

Patient Initials (Last, First Middle)

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)

PatientMedicalRecordNumber

Item

Patient Hospital No.

text

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25261 (NCI Thesaurus Property)
C0205476 (UMLS 2011AA Property)
C25198 (NCI Thesaurus Property)
C0034869 (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)

ParticipatingGroupName

Item

Participating Group

text

C25191 (NCI Thesaurus ValueDomain)
C1547383 (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)

ProtocolParticipatingIdentifierNumber

Item

Participating Group Study No.

text

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)

PatientParticipatingIdentifierNumber

Item

Participating Group 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)

Unnamed3

Item Group

Unnamed3

TreatingHospitalName

Item

Hospital Name (or imaging center performing chest CT)

text

C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C16696 (NCI Thesaurus ObjectClass)
C0019994 (UMLS 2011AA ObjectClass)
C25705 (NCI Thesaurus ObjectClass)
C1522326 (UMLS 2011AA ObjectClass)

Technique Factors

Item Group

Technique Factors

ChestComputedTomographyKilovoltPeakMeasurement

Item

KVp

double

C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)
C17204 (NCI Thesaurus ObjectClass)
C0040405 (UMLS 2011AA ObjectClass)
C25389 (NCI Thesaurus ObjectClass)
C0817096 (UMLS 2011AA ObjectClass)
C48432 (NCI Thesaurus Property)
C1708610 (UMLS 2011AA Property)

ChestComputedTomographyPitchMeasurement

Item

Pitch

double

C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)
C17204 (NCI Thesaurus ObjectClass)
C0040405 (UMLS 2011AA ObjectClass)
C25389 (NCI Thesaurus ObjectClass)
C0817096 (UMLS 2011AA ObjectClass)
C48442 (NCI Thesaurus Property)
C1704634 (UMLS 2011AA Property)

ChestComputedTomographyAmpereMeasurement

Item

double

ChestComputedTomographyScanLengthMeasurement

Item

Scan Length (craniocaudal extent)

double

C17204 (NCI Thesaurus ObjectClass)
C0040405 (UMLS 2011AA ObjectClass)
C25389 (NCI Thesaurus ObjectClass)
C0817096 (UMLS 2011AA ObjectClass)
C17999 (NCI Thesaurus Property)
C0441633 (UMLS 2011AA Property)
C25334 (NCI Thesaurus Property)
C1444754 (UMLS 2011AA Property)
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)

ChestComputedTomographyRevolutionTimeMeasurement

Item

Rotation Time

double

C17204 (NCI Thesaurus ObjectClass)
C0040405 (UMLS 2011AA ObjectClass)
C25389 (NCI Thesaurus ObjectClass)
C0817096 (UMLS 2011AA ObjectClass)
C25207 (NCI Thesaurus Property)
C0040223 (UMLS 2011AA Property)
C48439 (NCI Thesaurus Property)
C0035868 (UMLS 2011AA Property)
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)

Tumor Features

Item Group

Tumor Features

TumorLungAreaType

Item

Tumor Location Area (Mark one)

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C12468 (NCI Thesaurus Property)
C0024109 (UMLS 2011AA Property)
C25244 (NCI Thesaurus Property)
C0205146 (UMLS 2011AA Property)

CL.2

Code List

Tumor Location Area (Mark one)

CL Item

Upper Lobe (right) (Upper Lobe (right))

CL Item

Middle Lobe (right) (Middle Lobe (right))

CL Item

Lower Lobe (right) (Lower Lobe (right))

CL Item

Upper Lobe (left) (Upper Lobe (left))

CL Item

Lower Lobe (left) (Lower Lobe (left))

CL Item

Lingula (Lingula)

MostSuperiorComputedTomographyCoordinateAeratedLungPerformedText

Item

Table position of the most superior section in which aerated lung is visible (For the lung that contains the tumor provide:)

text

C17204 (NCI Thesaurus ObjectClass)
C0040405 (UMLS 2011AA ObjectClass)
C44465 (NCI Thesaurus ObjectClass)
C1707511 (UMLS 2011AA ObjectClass)
C25235 (NCI Thesaurus ObjectClass)
C1282910 (UMLS 2011AA ObjectClass)
C25258 (NCI Thesaurus ObjectClass)
C0205393 (UMLS 2011AA ObjectClass)
C12468 (NCI Thesaurus Property)
C0024109 (UMLS 2011AA Property)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)

MostSuperiorComputedTomographyCoordinateDiaphragmPerformedText

Item

Table position of the most superior section that shows the dome of the hemidiaphragm

text

C17204 (NCI Thesaurus ObjectClass)
C0040405 (UMLS 2011AA ObjectClass)
C44465 (NCI Thesaurus ObjectClass)
C1707511 (UMLS 2011AA ObjectClass)
C25235 (NCI Thesaurus ObjectClass)
C1282910 (UMLS 2011AA ObjectClass)
C25258 (NCI Thesaurus ObjectClass)
C0205393 (UMLS 2011AA ObjectClass)
C12702 (NCI Thesaurus Property)
C0011980 (UMLS 2011AA Property)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)

BestComputedTomographyCoordinateNeoplasmCenterPerformedText

Item

Table position of the section that best demonstrated the center of the tumor

text

C17204 (NCI Thesaurus ObjectClass)
C0040405 (UMLS 2011AA ObjectClass)
C25432 (NCI Thesaurus ObjectClass)
C1522427 (UMLS 2011AA ObjectClass)
C44465 (NCI Thesaurus ObjectClass)
C1707511 (UMLS 2011AA ObjectClass)
C3262 (NCI Thesaurus Property)
C0027651 (UMLS 2011AA Property)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C25445 (NCI Thesaurus Property)
C0205099 (UMLS 2011AA Property)
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)

BestComputedTomographyCoordinateMidlineCenterLengthMeasurement

Item

Distance from midline to center of tumor

text

C17204 (NCI Thesaurus ObjectClass)
C0040405 (UMLS 2011AA ObjectClass)
C25432 (NCI Thesaurus ObjectClass)
C1522427 (UMLS 2011AA ObjectClass)
C44465 (NCI Thesaurus ObjectClass)
C1707511 (UMLS 2011AA ObjectClass)
C0549183 (NCI Metathesaurus Property)
C25445 (NCI Thesaurus Property)
C0205099 (UMLS 2011AA Property)
C25334 (NCI Thesaurus Property)
C1444754 (UMLS 2011AA Property)
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)

ComputedTomographyCoordinateAeratedLungAnteriorPosteriorLengthMeasurement

Item

Maximum anteroposterior extent of aerated lung (same side as tumor)

text

C17204 (NCI Thesaurus ObjectClass)
C0040405 (UMLS 2011AA ObjectClass)
C44465 (NCI Thesaurus ObjectClass)
C1707511 (UMLS 2011AA ObjectClass)
C12468 (NCI Thesaurus Property)
C0024109 (UMLS 2011AA Property)
C25231 (NCI Thesaurus Property)
C0205094 (UMLS 2011AA Property)
C25622 (NCI Thesaurus Property)
C0205095 (UMLS 2011AA Property)
C25334 (NCI Thesaurus Property)
C1444754 (UMLS 2011AA Property)
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)

ComputedTomographyCoordinateAeratedLungPosteriorCenterLengthMeasurement

Item

Distance from the most posterior extent of aerated lung to center of tumor

text

C17204 (NCI Thesaurus ObjectClass)
C0040405 (UMLS 2011AA ObjectClass)
C44465 (NCI Thesaurus ObjectClass)
C1707511 (UMLS 2011AA ObjectClass)
C12468 (NCI Thesaurus Property)
C0024109 (UMLS 2011AA Property)
C25622 (NCI Thesaurus Property)
C0205095 (UMLS 2011AA Property)
C25445 (NCI Thesaurus Property)
C0205099 (UMLS 2011AA Property)
C25334 (NCI Thesaurus Property)
C1444754 (UMLS 2011AA Property)
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)

ChestComputedTomographyNeoplasmMaximumDiameterLengthMeasurement

Item

Maximum diameter of tumor using lung window settings

text

C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C17204 (NCI Thesaurus ObjectClass)
C0040405 (UMLS 2011AA ObjectClass)
C25389 (NCI Thesaurus ObjectClass)
C0817096 (UMLS 2011AA ObjectClass)
C25285 (NCI Thesaurus Property)
C1301886 (UMLS 2011AA Property)
C25564 (NCI Thesaurus Property)
C0806909 (UMLS 2011AA Property)
C25334 (NCI Thesaurus Property)
C1444754 (UMLS 2011AA Property)
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)

ChestAbdominalCavityComputedTomographyNeoplasmMaximumDiameterLengthMeasurement

Item

Maximum diameter of tumor, using soft tissue (chest/abdomen) window settings

text

C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C17204 (NCI Thesaurus ObjectClass)
C0040405 (UMLS 2011AA ObjectClass)
C25389 (NCI Thesaurus ObjectClass)
C0817096 (UMLS 2011AA ObjectClass)
C12664 (NCI Thesaurus ObjectClass)
C0230168 (UMLS 2011AA ObjectClass)
C25285 (NCI Thesaurus Property)
C1301886 (UMLS 2011AA Property)
C25564 (NCI Thesaurus Property)
C0806909 (UMLS 2011AA Property)
C25334 (NCI Thesaurus Property)
C1444754 (UMLS 2011AA Property)
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)

Tumor Features (cont)

Item Group

Tumor Features (cont)

PatientPriorChestComputedTomographyInd-2

Item

Is a previous CT scan available for comparison

text

C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25629 (NCI Thesaurus Property)
C0332152 (UMLS 2011AA Property)
C0202823 (NCI Metathesaurus Property)

CL.3

Code List

Is a previous CT scan available for comparison

CL Item

No (No)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

TumorChangeType

Item

Has the tumor changed

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C25446 (NCI Thesaurus Property)
C0392747 (UMLS 2011AA Property)

CL.4

Code List

Has the tumor changed

CL Item

New Finding (New finding)

CL Item

Tumor Size Increased (Tumor size increased)

CL Item

Tumor Size Decreased (Tumor size decreased)

TumorPriorMaximumDiameterMeasurement

Item

Indicate previous maximum diameter (on lung window images - cm)

double

C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C25285 (NCI Thesaurus Property)
C1301886 (UMLS 2011AA Property)
C25629 (NCI Thesaurus Property)
C0332152 (UMLS 2011AA Property)
C25564 (NCI Thesaurus Property)
C0806909 (UMLS 2011AA Property)
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)

PriorChestComputedTomographyPerformedDate

Item

Date of previous scan

date

C17204 (NCI Thesaurus ObjectClass)
C0040405 (UMLS 2011AA ObjectClass)
C25389 (NCI Thesaurus ObjectClass)
C0817096 (UMLS 2011AA ObjectClass)
C25629 (NCI Thesaurus ObjectClass)
C0332152 (UMLS 2011AA ObjectClass)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)

Tumor Appearance

Item Group

Tumor Appearance

TumorMarginType

Item

Margin and shape based on lung window settings (Mark all that apply with an X.)

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C25563 (NCI Thesaurus Property)
C0205284 (UMLS 2011AA Property)

CL.5

Code List

Margin and shape based on lung window settings (Mark all that apply with an X.)

CL Item

Well Defined (Well-defined)

C0442825 (NCI Metathesaurus)

CL Item

Ill-defined (Ill-defined)

CL Item

Lobulated (Lobulated)

CL Item

Spiculated (Spiculated)

CL Item

Round (Round)

C48348 (NCI Thesaurus)
C0332490 (UMLS 2011AA)

TumorAppearanceType

Item

Tumor appearance on lung window settings (Mark all that apply with an X.)

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C25377 (NCI Thesaurus Property)
C0700364 (UMLS 2011AA Property)

CL.6

Code List

Tumor appearance on lung window settings (Mark all that apply with an X.)

CL Item

Solid: C45300 (Solid)

C45300 (NCI Thesaurus)
C0205208 (UMLS 2011AA)

CL Item

Part Solid/mixed (Part-Solid)

ChestAbdomenCavityComputedTomographyNeoplasmAppearanceType

Item

If the scan includes non-contrast enhanced images of the tumor, are any of the following present (Tumor appearance on soft tissue chest/abdomen window settings)

text

C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C17204 (NCI Thesaurus ObjectClass)
C0040405 (UMLS 2011AA ObjectClass)
C25389 (NCI Thesaurus ObjectClass)
C0817096 (UMLS 2011AA ObjectClass)
C12664 (NCI Thesaurus ObjectClass)
C0230168 (UMLS 2011AA ObjectClass)
C25377 (NCI Thesaurus Property)
C0700364 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)

CL.7

Code List

If the scan includes non-contrast enhanced images of the tumor, are any of the following present (Tumor appearance on soft tissue chest/abdomen window settings)

CL Item

High- Attenuation Foci (e.g., Calcification) (High- attenuation foci (e.g., calcification))

CL Item

Water- Attenuation Foci (e.g., Necrosis) (Water- attenuation foci (e.g., necrosis))

CL Item

Gas- Attenuation Foci (Gas- attenuation foci)

ChestAbdominalCavityComputedTomographyNeoplasmContrastAppearanceType

Item

If the scan includes contrast-enhanced images of the tumor, are any of the following present within the tumor (Tumor appearance on soft tissue chest/abdomen window settings)

text

C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C17204 (NCI Thesaurus ObjectClass)
C0040405 (UMLS 2011AA ObjectClass)
C25389 (NCI Thesaurus ObjectClass)
C0817096 (UMLS 2011AA ObjectClass)
C12664 (NCI Thesaurus ObjectClass)
C0230168 (UMLS 2011AA ObjectClass)
C25377 (NCI Thesaurus Property)
C0700364 (UMLS 2011AA Property)
C43290 (NCI Thesaurus Property)
C1711375 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)

CL.8

Code List

If the scan includes contrast-enhanced images of the tumor, are any of the following present within the tumor (Tumor appearance on soft tissue chest/abdomen window settings)

CL Item

High- Attenuation Foci (e.g., Calcification) (High- attenuation foci (e.g., calcification))

CL Item

Water- Attenuation Foci (e.g., Necrosis) (Water- attenuation foci (e.g., necrosis))

CL Item

Gas- Attenuation Foci (Gas- attenuation foci)

Lymph Nodes

Item Group

Lymph Nodes

LungLymphNodeSwellingAssessmentSite

Item

Indicate stations of all enlarged lymph nodes

text

C12468 (NCI Thesaurus ObjectClass)
C0024109 (UMLS 2011AA ObjectClass)
C12745 (NCI Thesaurus ObjectClass)
C0024204 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C3399 (NCI Thesaurus Property)
C0038999 (UMLS 2011AA Property)
C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)

CL.9

Code List

Indicate stations of all enlarged lymph nodes

CL Item

Left Hilar Node (Left hilar (10L))

CL Item

Left Lower Paratracheal Node (Left lower paratracheal (4L))

CL Item

Left Pulmonary Ligament (9l) (Left pulmonary ligament (9L))

CL Item

Left Upper Paratracheal Node (Left upper paratracheal (2L))

CL Item

Para-aortic Node (Para-aortic (6))

CL Item

Paraesophageal (Paraesophageal (8))

C25344 (NCI Thesaurus)
C0475302 (UMLS 2011AA)

CL Item

Pre-vascular (3a) (Pre-vascular (3A))

CL Item

Retrotracheal (3p) (Retrotracheal (3P))

CL Item

Right Hilar Node (Right hilar (10R))

CL Item

Right Lower Paratracheal Node (Right lower paratracheal (4R))

CL Item

Right Pulmonary Ligament (9r) (Right pulmonary ligament (9R))

CL Item

Right Upper Paratracheal Node (Right upper paratracheal (2R))

CL Item

Subaortic Node (Subaortic (5))

CL Item

Subcarinal Node (Subcarinal (7))

PriorTreatmentPositronEmissionTomographyInterpretationAvailableInd-2

Item

Was a pre-operative PET scan performed

text

C17007 (NCI Thesaurus ObjectClass)
C0032743 (UMLS 2011AA ObjectClass)
C25629 (NCI Thesaurus ObjectClass)
C0332152 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass)
C25429 (NCI Thesaurus Property)
C0470187 (UMLS 2011AA Property)
C41255 (NCI Thesaurus Property)
C0459471 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)

CL.10

Code List

Was a pre-operative PET scan performed

CL Item

No (No)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

PatientPre-studyChestPositronEmissionTomographyEligibilityDate

Item

Date of PET scan (If yes,)

date

C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17007 (NCI Thesaurus Property)
C0032743 (UMLS 2011AA Property)
C25389 (NCI Thesaurus Property)
C0817096 (UMLS 2011AA Property)
C25171 (NCI Thesaurus Property)
C0013893 (UMLS 2011AA Property)
C38010 (NCI Thesaurus Property)
C1527048 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)

PET Scan Results

Item Group

Pet Scan Results

PositronEmissionTomographyMedicalImagingLungNeoplasmAssessmentAnatomicSite

Item

Site of lesion

text

C17007 (NCI Thesaurus ObjectClass)
C0032743 (UMLS 2011AA ObjectClass)
C16831 (NCI Thesaurus ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C3200 (NCI Thesaurus Property)
C0020445 (UMLS 2011AA Property)
C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)

CL.11

Code List

Site of lesion

CL Item

Lymph Node (Nodal lesion)

C12745 (NCI Thesaurus)
C0024204 (UMLS 2011AA)

CL Item

Other (Other lesion)

C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)

CL Item

Lung (Primary Lung)

C12468 (NCI Thesaurus)
C0024109 (UMLS 2011AA)

PositronEmissionTomographyMedicalImagingLungNeoplasmAssessmentSpecify

Item

Nodal lesion, specify

text

C17007 (NCI Thesaurus ObjectClass)
C0032743 (UMLS 2011AA ObjectClass)
C16831 (NCI Thesaurus ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C3200 (NCI Thesaurus Property)
C0020445 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)

StandardUptakeValuePositronEmissionTomographyAssessmentMaximumMeasurement

Item

SUV Max

double

C17007 (NCI Thesaurus ObjectClass)
C0032743 (UMLS 2011AA ObjectClass)
C44275 (NCI Thesaurus ObjectClass)
C1442989 (UMLS 2011AA ObjectClass)
C0243144 (NCI Metathesaurus ObjectClass)
C25712 (NCI Thesaurus ObjectClass)
C1522609 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)
C25564 (NCI Thesaurus ValueDomain)
C0806909 (UMLS 2011AA ValueDomain)

StandardUptakeValuePositronEmissionTomographyAssessmentMeanMeasurement

Item

SUV Mean

double

C17007 (NCI Thesaurus ObjectClass)
C0032743 (UMLS 2011AA ObjectClass)
C44275 (NCI Thesaurus ObjectClass)
C1442989 (UMLS 2011AA ObjectClass)
C0243144 (NCI Metathesaurus ObjectClass)
C25712 (NCI Thesaurus ObjectClass)
C1522609 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)
C53319 (NCI Thesaurus ValueDomain)
C0444504 (UMLS 2011AA ValueDomain)

DiagnosticProcedureLungDistantMetastasisPresentPerformedText

Item

What tests were performed to rule out possible distant metastases present on PET scan?

text

C18020 (NCI Thesaurus ObjectClass)
C0430022 (UMLS 2011AA ObjectClass)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C12468 (NCI Thesaurus Property)
C0024109 (UMLS 2011AA Property)
C18206 (NCI Thesaurus Property)
C1269798 (UMLS 2011AA Property)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)

Footer

Item Group

Footer

ResponsiblePersonName

Item

Completed by (Last name, First name)

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)

FormOriginalCompleteDate

Item

Date Form Originally Completed

date

C19464 (NCI Thesaurus ObjectClass)
C0376315 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25604 (NCI Thesaurus Property)
C0205313 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain)

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On-Study - CALGB: Imaging Form - 2730039v1.0

Instructions: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice...

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