Description:

E3F05 Primary Brain Tumor Follow-Up Disease Evaluation Form Radiation Therapy With or Without Temozolomide in Treating Patients With Low-Grade Glioma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=6CB91C46-8BDC-9A0D-E040-BB89AD433170

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https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=6CB91C46-8BDC-9A0D-E040-BB89AD433170

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  1. 8/26/12
  2. 1/8/15
Uploaded on:

January 8, 2015

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Creative Commons BY-NC 3.0 Legacy
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Brain and Central Nervous System Tumors NCT00978458 Follow-Up - E3F05 Primary Brain Tumor Follow-Up Disease Evaluation Form - 2902962v1.0

INSTRUCTIONS: Complete this form and submit original to the ECOG Coordinating Center according to the forms submission schedule. If the same lesion was assessed more than once during a report period, submit additional forms (record all lesions on each form). Submit this form at each report period until progression regardless of whether a scan was done. Keep a copy for your files

Header
Unnamed2
On Treatment
On Treatment Report Period (Choose one since start of treatment)
Off Treatment
Off Treatment Report Period (Choose one since start of registration)
Section Iii
Is the patient receiving corticosteroids?
Name of Medication (If yes)
Has dose of corticosteroids changed
Increased due to suspected PD (If yes, increase)
Section I Measurable Lesions
Were imaging studies performed (scan this report period)
Was measurable disease present (at baseline)
Was enhancing measureable disease present at baseline (if yes, complete T2/FLAIR section below and T1/Contrast section below with current assessment results)
Was non-enhancing measureable disease present at baseline (if yes, complete T2/FLAIR section below with current assessment results)
Unnamed3
Tumor Laterality
Site
Does tumor cross midline
Unnamed3
Tumor Laterality
Site
Does tumor cross midline
Section Ii Non-measurable Lesions
Was non-measurable disease present (at baseline)
Was enhancing non-measureable disease present at baseline (if yes, complete T2/FLAIR section below and T1/Contrast section below with current assessment results - NOTE: If there is NEW enhancement in a previously reported lesion, report this newly enhancing component in Section IV, New CNS Lesions/New Enhancements of Previously Reported Lesions under the T1/Contrast section.)
Was non-enhancing non-measureable disease present at baseline (if yes, complete T2/FLAIR section below with current assessment results)
Nontarget Lesions
Did this lesion progress
Tumor Laterality
Site
Does tumor cross midline
Nontarget Lesions
Did this lesion progress
Tumor Laterality
Site
Does tumor cross midline
Section Iv New Cns Lesions
Was the appearance of any new lesions or new enhancement of previously reported lesions documented (CNS)
Nontarget Lesions
Tumor Laterality
Site
Does tumor cross midline
Nontarget Lesions
Tumor Laterality
Site
Does tumor cross midline
Section V Progression
Has the patient developed a first progression (or relapse) that has not been previously reported?
What was the method used to determine progression (primary - Clinical/Neurological progression is defined as 1 NFS of "4", or 2 NFS drop of 2 levels, or 3 increase or start of corticosteroids for control of neurologic symptoms)
Is patient receiving further antitumoral therapy (Further antitumoral treatment following diagnosis of progression)
Specify (If yes)
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