ID

7236

Beschreibung

Primary Amyloidosis - On-Study Form Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=D6E2AA52-99FE-5B44-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=D6E2AA52-99FE-5B44-E034-0003BA12F5E7

Stichworte

Hochgeladen am

9. Januar 2015

DOI

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Lizenz

Creative Commons BY-NC 3.0 Legacy

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On-Study - Primary Amyloidosis - On-Study Form - 2275605v3.0

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1 Formulare

StudyEvent: Primary Amyloidosis - On-Study Form
1. No Instruction available.

Name

Typ

Description | Question | Decode (Coded Value)

Datentyp

Alias

CRF Header

Item Group

Crf Header

Protocol ID Coordinating Group

Item

Coordinating Group Protocol No.

text

C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1711341 (UMLS CUI-2)
C25462 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)

Coordinating Group Code

Item

Coordinating Group Code

text

C25162 (NCI Thesaurus ValueDomain)
C1711341 (UMLS CUI-1)
C17005 (NCI Thesaurus ObjectClass)
C0805701 (UMLS CUI-2)
C25462 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)

Protocol Title

Item

Protocol Title

text

C25191 (NCI Thesaurus ValueDomain)
C2986303 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C42774 (NCI Thesaurus Property)

Patient Study ID

Item

Patient Study ID

text

C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25462 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)

Institution Name

Item

Institution/Affiliate

text

C25454 (NCI Thesaurus ObjectClass)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
C25191 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ValueDomain-2)

Trial subject ID Participating Group

Item

Other Patient ID

text

C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)

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-2)
C1257890 (UMLS 2011AA ObjectClass-2)
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)

Amyloid: Form Administration

Item Group

Amyloid: Form Administration

Person Completing Form

Item

Person Completing Form

text

C25191 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)

Data amended

Item

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

boolean

C38148 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)

Amyloid: Disease Description

Item Group

Amyloid: Disease Description

CancerInitialDiagnosisDate

Item

Date of Initial Pathologic Diagnosis

date

C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
C25509 (NCI Thesaurus Property)
C1279901 (UMLS 2011AA Property)
C15220 (NCI Thesaurus Property-2)
C0011900 (UMLS 2011AA Property-2)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)

HeartInvolvedInd-3

Item

Heart (Clinical Involvement?* Y=yes, N=no *Symptomatic)

boolean

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C12727 (NCI Thesaurus ObjectClass)
C0018787 (UMLS 2011AA ObjectClass)
C25547 (NCI Thesaurus Property)

KidneyDiseasePresentInd-3

Item

Kidney

boolean

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C12415 (NCI Thesaurus ObjectClass)
C0022646 (UMLS 2011AA ObjectClass)
C2991 (NCI Thesaurus ObjectClass-2)
C0012634 (UMLS 2011AA ObjectClass-2)

LiverInvolvedInd-3

Item

Liver

boolean

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C12392 (NCI Thesaurus ObjectClass)
C0023884 (UMLS 2011AA ObjectClass)
C25547 (NCI Thesaurus Property)

StomachInvolvedInd-3

Item

Stomach

boolean

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25547 (NCI Thesaurus Property)
C0038351 (NCI Metathesaurus ObjectClass)

SmallBowelGastrointestinalInvolvedInd-3

Item

Gastrointestinal/small bowel

boolean

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C13359 (NCI Thesaurus Property)
C0521362 (UMLS 2011AA Property)
C12386 (NCI Thesaurus ObjectClass)
C0021852 (UMLS 2011AA ObjectClass)
C25547 (NCI Thesaurus Property-2)

RectumColonInvolvedInd-3

Item

Colon/rectum

boolean

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C12382 (NCI Thesaurus ObjectClass)
C0009368 (UMLS 2011AA ObjectClass)
C12390 (NCI Thesaurus ObjectClass-2)
C0034896 (UMLS 2011AA ObjectClass-2)
C25547 (NCI Thesaurus Property)

PeripheralNeuropathySymptomInd-3

Item

Peripheral Nerve Neuropathy

boolean

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
C4731 (NCI Thesaurus ObjectClass)
C0031117 (UMLS 2011AA ObjectClass)
C25233 (NCI Thesaurus ObjectClass-2)
C0205100 (UMLS 2011AA ObjectClass-2)

SoftTissueInvolvedInd-3

Item

Soft Tissue

boolean

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25547 (NCI Thesaurus Property)
C12801 (NCI Thesaurus ObjectClass)
C0040300 (UMLS 2011AA ObjectClass)
C25255 (NCI Thesaurus ObjectClass-2)
C0205358 (UMLS 2011AA ObjectClass-2)

SkinInvolvedInd-3

Item

Skin

boolean

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C12470 (NCI Thesaurus ObjectClass)
C1123023 (UMLS 2011AA ObjectClass)
C25547 (NCI Thesaurus Property)

MacroglossiaSymptomInd-3

Item

Macroglossia

boolean

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
C0024421 (NCI Metathesaurus ObjectClass)

AutonomicNeuropathyInvolvedInd-3

Item

Autonomic Nerve Neuropathy (** Note: Autonomic neuropathy includes any gastroparesis, pseudo-obstruction, and/or orthostatic hypotension not attributable to medications or volume depletion.)

boolean

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25547 (NCI Thesaurus Property)
C27033 (NCI Thesaurus ObjectClass)
C0259749 (UMLS 2011AA ObjectClass)

OtherSiteInvolvedInd-3

Item

Other

boolean

C17649 (NCI Thesaurus ObjectClass)
C0205394 (UMLS 2011AA ObjectClass)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25547 (NCI Thesaurus Property)
CL111053 (NCI Metathesaurus ObjectClass)

OtherDiseaseSiteName

Item

Other Site Name (If yes,)

text

C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C17649 (NCI Thesaurus ObjectClass)
C0205394 (UMLS 2011AA ObjectClass)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C2991 (NCI Thesaurus ObjectClass-2)
C0012634 (UMLS 2011AA ObjectClass-2)

BiopsyPerformedInd-3

Item

Biopsy done (Y=yes, N=no)

boolean

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C15189 (NCI Thesaurus ObjectClass)
C0005558 (UMLS 2011AA ObjectClass)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)

BiopsyResultType

Item

Biopsy Result (If done,)

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C15189 (NCI Thesaurus ObjectClass)
C0005558 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)

CL.15

Code List

Biopsy Result (If done,)

CL Item

Positive (Positive)

C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)

CL Item

Negative (Negative)

C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

DominantMyelomaSymptomType

Item

Dominant Presentation (at Diagnosis check only one)

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C3242 (NCI Thesaurus ObjectClass)
C0026764 (UMLS 2011AA ObjectClass)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
C25487 (NCI Thesaurus ObjectClass-2)
C1527180 (UMLS 2011AA ObjectClass-2)

CL.16

Code List

Dominant Presentation (at Diagnosis check only one)

CL Item

Heart (Heart)

C12727 (NCI Thesaurus)
C0018787 (UMLS 2011AA)

CL Item

Kidney (Kidney)

C12415 (NCI Thesaurus)
C0022646 (UMLS 2011AA)

CL Item

Liver (Liver)

C12392 (NCI Thesaurus)
C0023884 (UMLS 2011AA)

CL Item

Stomach (stomach)

C12391 (NCI Thesaurus)
C0038351 (UMLS 2011AA)

CL Item

Gastrointestinal/small Bowel (Gastrointestinal/small bowel)

CL Item

Colon/rectum (Colon/rectum)

CL Item

Peripheral Nerve Neuropathy (Peripheral Nerve Neuropathy)

CL Item

Autonomic Nerve Neuropathy (Autonomic Nerve Neuropathy)

CL Item

Soft Tissue (Soft Tissue)

C12471 (NCI Thesaurus)
C0225317 (UMLS 2011AA)

CL Item

Skin (Skin)

C12470 (NCI Thesaurus)
C1123023 (UMLS 2011AA)

CL Item

Macroglossia (Macroglossia)

CL Item

Other (Other)

C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)

DominantMyelomaSymptomSpecify

Item

Other specify

text

C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C3242 (NCI Thesaurus ObjectClass)
C0026764 (UMLS 2011AA ObjectClass)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
C25487 (NCI Thesaurus ObjectClass-2)
C1527180 (UMLS 2011AA ObjectClass-2)

MyelomaSymptomType

Item

Disease Symptoms Present (at Diagnosis)

text

CL.17

Code List

Disease Symptoms Present (at Diagnosis)

CL Item

Fatigue (Fatigue)

C3036 (NCI Thesaurus)
C0015672 (UMLS 2011AA)

CL Item

Leg Swelling (Leg swelling)

CL Item

Painful/numb Feet (Painful/numb feet)

CL Item

Carpal Tunnel (Carpal tunnel)

CL Item

Purpura (skin) (Purpura (skin))

CL Item

Diarrhea (Diarrhea)

C2987 (NCI Thesaurus)
C0011991 (UMLS 2011AA)

CL Item

Syncope (Syncope)

C35053 (NCI Thesaurus)
C0039070 (UMLS 2011AA)

CL Item

Light-headedness (Light-headedness)

CL Item

Macroglossia (Macroglossia)

CL Item

Weight Loss >= 10% Of Body Weight (Weight loss >= 10% of body weight)

CL Item

Other (Other)

C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)

MyelomaSymptomSpecify

Item

Other specify

text

LaboratoryProcedureTotalSerumProteinOutcomeUnspecifiedValue

Item

Serum Total Protein (SPEP at diagnosis)

float

C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C25304 (NCI Thesaurus Property)
C0439810 (UMLS 2011AA Property)
C20200 (NCI Thesaurus Property-2)
C1274040 (UMLS 2011AA Property-2)
C17126 (NCI Thesaurus Property-3)
C0036825 (UMLS 2011AA Property-3)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)

LaboratoryProcedureSerumMProteinOutcomeUnspecifiedValue

Item

Serum M-Protein Spike (SPEP If immunofixation is positive but M-spike is not quantifiable, enter .01 or follow protocol guidelines for entering M-spike.)

float

C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C13325 (NCI Thesaurus Property)
C0229671 (UMLS 2011AA Property)
C20200 (NCI Thesaurus Property-2)
C1274040 (UMLS 2011AA Property-2)
C17788 (NCI Thesaurus Property-3)
C0700271 (UMLS 2011AA Property-3)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)

SerumProteinMonoclonalDetectedType

Item

Serum M-Protein by Immunofixation (at diagnosis)

text

C13325 (NCI Thesaurus ObjectClass)
C0229671 (UMLS 2011AA ObjectClass)
C17021 (NCI Thesaurus ObjectClass-2)
C0033684 (UMLS 2011AA ObjectClass-2)
C0746619 (NCI Metathesaurus Property)
C25481 (NCI Thesaurus Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)

CL.19

Code List

Serum M-Protein by Immunofixation (at diagnosis)

CL Item

Negative (Negative)

C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)

CL Item

Positive (Positive)

C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)

CL Item

Equivocal (Equivocal)

C86071 (NCI Thesaurus)
C0332241 (UMLS 2011AA)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

LaboratoryProcedureImmunoglobulinHeavyChainOutcomeType

Item

Serum Heavy Chain (If positive or equivocal, check all that apply)

text

C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C16717 (NCI Thesaurus Property)
C0021034 (UMLS 2011AA Property)
C13325 (NCI Thesaurus Property-2)
C0229671 (UMLS 2011AA Property-2)
C20200 (NCI Thesaurus Property-3)
C1274040 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)

CL.20

Code List

Serum Heavy Chain (If positive or equivocal, check all that apply)

CL Item

G (G)

CL Item

A (A)

C14653 (NCI Thesaurus)

CL Item

M (M)

CL Item

D (D)

C25321 (NCI Thesaurus)
C0443203 (UMLS 2011AA)

CL Item

E (E)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

LaboratoryProcedureImmunoglobulinLightChainProteinResultType

Item

Serum Light Chain (check all that apply)

text

C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C17021 (NCI Thesaurus Property-2)
C0033684 (UMLS 2011AA Property-2)
C16720 (NCI Thesaurus Property-3)
C0021038 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)

CL.21

Code List

Serum Light Chain (check all that apply)

CL Item

Kappa (Kappa)

CL Item

Lambda (Lambda)

C0926407 (NCI Metathesaurus)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

LaboratoryProcedureBiclonalGammopathyOutcomeInd-2

Item

Biclonal

boolean

C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C74936 (NCI Thesaurus Property-2)

LaboratoryProcedureBiclonalGammopathyOutcomeSpecify

Item

Yes specify

text

C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C74936 (NCI Thesaurus Property-2)

SerumProteinOligoclonalInd-2

Item

Oligoclonal

boolean

C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C0229671 (NCI Metathesaurus ObjectClass)
CL145970 (NCI Metathesaurus Property)

SerumOligoclonalProteinSpecify

Item

Yes specify

text

C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C0229671 (NCI Metathesaurus ObjectClass)
CL145970 (NCI Metathesaurus Property)

LaboratoryProcedureTotalUrineProteinOutcomeUnspecifiedValue

Item

Urine Total Protein (UPEP at diagnosis)

float

C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C25304 (NCI Thesaurus Property)
C0439810 (UMLS 2011AA Property)
C13283 (NCI Thesaurus Property-2)
C0042036 (UMLS 2011AA Property-2)
C20200 (NCI Thesaurus Property-3)
C1274040 (UMLS 2011AA Property-3)
C17021 (NCI Thesaurus Property-4)
C0033684 (UMLS 2011AA Property-4)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)

LaboratoryProcedureUrineMProteinImmunoglobulinLightChainOutcomeUnspecifiedValue

Item

Urine M-Protein Light Chain Excretion (If immunofixation is positive but M-protein is not quantifiable, enter .01 or follow protocol guidelines for entering M-protein.)

float

C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C13283 (NCI Thesaurus Property)
C0042036 (UMLS 2011AA Property)
C20200 (NCI Thesaurus Property-2)
C1274040 (UMLS 2011AA Property-2)
C17788 (NCI Thesaurus Property-3)
C0700271 (UMLS 2011AA Property-3)
C16720 (NCI Thesaurus Property-4)
C0021038 (UMLS 2011AA Property-4)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)

AssessmentLabUOM

Item

Unit of Measure

text

C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C37984 (NCI Thesaurus Property)
C0022877 (UMLS 2011AA Property)
C25709 (NCI Thesaurus ValueDomain)
C1519795 (UMLS 2011AA ValueDomain)

CL.24

Code List

Unit of Measure

CL Item

Milligrams/24 Hours (mg/24 hrs)

CL Item

Grams/24 Hours (g/24 hrs)

AssessmentLabUOM

Item

Unit of Measure

text

CL.24

Code List

Unit of Measure

CL Item

Milligrams/24 Hours (mg/24 hrs)

CL Item

Grams/24 Hours (g/24 hrs)

MonoclonalProteinUrineImmunofixationType

Item

Urine M-Protein by Immunofixation (at diagnosis)

text

C17021 (NCI Thesaurus ObjectClass)
C0033684 (UMLS 2011AA ObjectClass)
C0746619 (NCI Metathesaurus ObjectClass)
C13283 (NCI Thesaurus Property)
C0042036 (UMLS 2011AA Property)
CL201583 (NCI Metathesaurus Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)

CL.25

Code List

Urine M-Protein by Immunofixation (at diagnosis)

CL Item

Negative (Negative)

C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)

CL Item

Positive (Positive)

C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)

CL Item

Equivocal (Equivocal)

C86071 (NCI Thesaurus)
C0332241 (UMLS 2011AA)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

UrineProteinLightChainAnalysisImmunofixationType

Item

Urine Light Chain (If positive or equivocal,)

text

C13283 (NCI Thesaurus ObjectClass)
C0042036 (UMLS 2011AA ObjectClass)
C17021 (NCI Thesaurus ObjectClass-2)
C0033684 (UMLS 2011AA ObjectClass-2)
CL201583 (NCI Metathesaurus Property)
CL105192 (NCI Metathesaurus Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)

CL.26

Code List

Urine Light Chain (If positive or equivocal,)

CL Item

Kappa (Kappa)

CL Item

Lambda (Lambda)

C0926407 (NCI Metathesaurus)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

Amyloid: Prior Treatment

Item Group

Amyloid: Prior Treatment

CancerPriorTreatmentInd-3

Item

Prior Treatment? (If yes, respond to treatment-specific questions below.)

boolean

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
C25629 (NCI Thesaurus Property)
C0332152 (UMLS 2011AA Property)
C15368 (NCI Thesaurus Property-2)

PriorTreatmentPlannedRegimenCount

Item

No. of Planned Regimens (If yes, Note: Multiple drug/staged regimens count as 1; e.g., VAD + transplant)

float

C25629 (NCI Thesaurus ObjectClass)
C0332152 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass-2)
C25619 (NCI Thesaurus Property)
C1301732 (UMLS 2011AA Property)
C15697 (NCI Thesaurus Property-2)
C0040808 (UMLS 2011AA Property-2)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)

MyelomaTreatmentPriorRegimenType

Item

Prior Treatment Regimen Name(s) (* Prior Treatment Regimen Name)

text

C3242 (NCI Thesaurus ObjectClass)
C0026764 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass-2)
C25629 (NCI Thesaurus Property)
C0332152 (UMLS 2011AA Property)
C15697 (NCI Thesaurus Property-2)
C0040808 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)

CL.28

Code List

Prior Treatment Regimen Name(s) (* Prior Treatment Regimen Name)

CL Item

Adriamycin (Adriamycin)

CL Item

Alpha-interferon (Alpha-interferon)

CL Item

Carmustine (bcnu) (Carmustine (BCNU))

CL Item

Colchicine (Colchicine)

C385 (NCI Thesaurus)
C0009262 (UMLS 2011AA)

CL Item

Cyclophosphamide (Cyclophosphamide)

C405 (NCI Thesaurus)
C0010583 (UMLS 2011AA)

CL Item

Dexamethasone (Dexamethasone)

C422 (NCI Thesaurus)
C0011777 (UMLS 2011AA)

CL Item

Iododeoxyrubicin (Iododeoxyrubicin)

CL Item

Melphalan (lpam) (Melphalan (LPAM))

CL Item

Mp (MP)

CL Item

Ps-341 (PS-341)

CL Item

Revimid (Revimid)

CL Item

Thalidomide (Thalidomide)

C870 (NCI Thesaurus)
C0039736 (UMLS 2011AA)

CL Item

Vincristine (vcr) (Vincristine (VCR))

CL Item

Vad (VAD)

CL Item

Prednisone (Prednisone)

C770 (NCI Thesaurus)
C0032952 (UMLS 2011AA)

CL Item

Corticosteroids (Corticosteroids)

CL Item

Interferon (Interferon)

C20493 (NCI Thesaurus)
C0733470 (UMLS 2011AA)

CL Item

Other (Other)

C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)

PriorTreatmentRegimenSpecify

Item

Other Prior Regimen Name (** If Other specify)

text

C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25629 (NCI Thesaurus ObjectClass)
C0332152 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass-2)
C15697 (NCI Thesaurus Property)
C0040808 (UMLS 2011AA Property)

PriorTreatmentRegimenBeginDate

Item

Prior Treatment Regimen Start Date

date

C25629 (NCI Thesaurus ObjectClass)
C0332152 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass-2)
C15697 (NCI Thesaurus Property)
C0040808 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25431 (NCI Thesaurus ValueDomain-2)
C0439659 (UMLS 2011AA ValueDomain-2)

PriorTreatmentRegimenEndDate

Item

Prior Treatment Regimen End Date

date

C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25629 (NCI Thesaurus ObjectClass)
C0332152 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass-2)
C15697 (NCI Thesaurus Property)
C0040808 (UMLS 2011AA Property)

PriorTreatmentDiscontinuedReason

Item

Reason Stopped (? Reason Stopped)

text

C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C25629 (NCI Thesaurus ObjectClass)
C0332152 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass-2)
C25484 (NCI Thesaurus Property)
C1444662 (UMLS 2011AA Property)

CL.29

Code List

Reason Stopped (? Reason Stopped)

CL Item

Completed Treatment (Completed treatment)

CL Item

Alternative Treatment (Alternative treatment)

CL Item

Response/improvement (Response/Improvement)

CL Item

Patient Refusal (Patient refusal)

CL Item

Toxicity (Toxicity)

C27990 (NCI Thesaurus)
C0600688 (UMLS 2011AA)

CL Item

Progression (Progression)

C25331 (NCI Thesaurus)
C25331 (NCI Thesaurus-2)

CL Item

Maintenance Only (Maintenance only)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

MyelomaTreatmentPriorResponseHematologicType

Item

Hematologic Response (? Hematologic Response)

text

C3242 (NCI Thesaurus ObjectClass)
C0026764 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass-2)
C25755 (NCI Thesaurus Property)
C0871261 (UMLS 2011AA Property)
C25629 (NCI Thesaurus Property-2)
C0332152 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)

CL.30

Code List

Hematologic Response (? Hematologic Response)

CL Item

Complete Response (Complete Response)

CL Item

Partial Response (Partial Response)

C18212 (NCI Thesaurus)

CL Item

Progression (Progression)

C25331 (NCI Thesaurus)

CL Item

Inevaluable (Inevaluable)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

MyelomaTreatmentPriorResponseOrganInd-3

Item

Organ Response (? Organ Response)

text

C3242 (NCI Thesaurus ObjectClass)
C0026764 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass-2)
C25755 (NCI Thesaurus Property)
C0871261 (UMLS 2011AA Property)
C25629 (NCI Thesaurus Property-2)
C0332152 (UMLS 2011AA Property-2)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C13018 (NCI Thesaurus ValueDomain-2)
C0178784 (UMLS 2011AA ValueDomain-2)

CL.31

Code List

Organ Response (? Organ Response)

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)

PriorBMSCTAdministeredInd-3

Item

Prior Bone Marrow or Peripheral Blood Stem Cell Transplant?

boolean

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25629 (NCI Thesaurus ObjectClass)
C0332152 (UMLS 2011AA ObjectClass)
C25437 (NCI Thesaurus ObjectClass-2)
C0842093 (UMLS 2011AA ObjectClass-2)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)

PriorTransplantAdministeredType

Item

Prior Transplant Type (If yes,)

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25629 (NCI Thesaurus ObjectClass)
C0332152 (UMLS 2011AA ObjectClass)
C12981 (NCI Thesaurus ObjectClass-2)
C0332835 (UMLS 2011AA ObjectClass-2)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)

CL.33

Code List

Prior Transplant Type (If yes,)

CL Item

Autologous (Autologous)

C28000 (NCI Thesaurus)
C0439859 (UMLS 2011AA)

CL Item

Allogeneic (Allogeneic)

AutologousTransplantPriorAdministeredCount

Item

Number of autologous transplants

float

C12981 (NCI Thesaurus ObjectClass)
C0332835 (UMLS 2011AA ObjectClass)
C28000 (NCI Thesaurus ObjectClass-2)
C0439859 (UMLS 2011AA ObjectClass-2)
C25629 (NCI Thesaurus Property)
C0332152 (UMLS 2011AA Property)
C25382 (NCI Thesaurus Property-2)
C1521801 (UMLS 2011AA Property-2)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)

PriorTransplantLastDate

Item

Date of Last Transplant

date

C25629 (NCI Thesaurus ObjectClass)
C0332152 (UMLS 2011AA ObjectClass)
C12981 (NCI Thesaurus ObjectClass-2)
C0332835 (UMLS 2011AA ObjectClass-2)
C25551 (NCI Thesaurus Property)
C1517741 (UMLS 2011AA Property)
C25275 (NCI Thesaurus Property-2)
C2745955 (UMLS 2011AA Property-2)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25551 (NCI Thesaurus ValueDomain-2)
C1517741 (UMLS 2011AA ValueDomain-2)

AllogeneicTransplantPriorAdministeredCount

Item

Number of allogeneic transplants

float

C12981 (NCI Thesaurus ObjectClass)
C0332835 (UMLS 2011AA ObjectClass)
C28343 (NCI Thesaurus ObjectClass-2)
C1515895 (UMLS 2011AA ObjectClass-2)
C25629 (NCI Thesaurus Property)
C0332152 (UMLS 2011AA Property)
C25382 (NCI Thesaurus Property-2)
C1521801 (UMLS 2011AA Property-2)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)

PriorTransplantAllogenicAdministeredType

Item

Allogeneic Transplant Type

text

C25629 (NCI Thesaurus ObjectClass)
C0332152 (UMLS 2011AA ObjectClass)
C12981 (NCI Thesaurus ObjectClass-2)
C0332835 (UMLS 2011AA ObjectClass-2)
C28343 (NCI Thesaurus Property)
C1515895 (UMLS 2011AA Property)
C25382 (NCI Thesaurus Property-2)
C1521801 (UMLS 2011AA Property-2)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)

CL.34

Code List

Allogeneic Transplant Type

CL Item

Mini (non-myeloablative) (Mini (non-myeloablative))

CL Item

Myeloablative (Myeloablative)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

PriorTransplantDate

Item

Date of Transplant

date

C25629 (NCI Thesaurus ObjectClass)
C0332152 (UMLS 2011AA ObjectClass)
C12981 (NCI Thesaurus ObjectClass-2)
C0332835 (UMLS 2011AA ObjectClass-2)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)

PriorTransplantLymphocyteInfusionInd-2

Item

DLI

boolean

C25629 (NCI Thesaurus ObjectClass)
C0332152 (UMLS 2011AA ObjectClass)
C12981 (NCI Thesaurus ObjectClass-2)
C0332835 (UMLS 2011AA ObjectClass-2)
C15388 (NCI Thesaurus Property)
C0574032 (UMLS 2011AA Property)
C12535 (NCI Thesaurus Property-2)
C0024264 (UMLS 2011AA Property-2)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)

PriorTransplantLymphocyteInfusionLastDate

Item

Date of Last DLI (If yes,)

date

C25629 (NCI Thesaurus ObjectClass)
C0332152 (UMLS 2011AA ObjectClass)
C12981 (NCI Thesaurus ObjectClass-2)
C0332835 (UMLS 2011AA ObjectClass-2)
C15388 (NCI Thesaurus Property)
C0574032 (UMLS 2011AA Property)
C12535 (NCI Thesaurus Property-2)
C0024264 (UMLS 2011AA Property-2)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25551 (NCI Thesaurus ValueDomain-2)
C1517741 (UMLS 2011AA ValueDomain-2)

PriorRTTotal-BodyIrradiationAdministeredInd-3

Item

Total body irradiation

text

C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C25629 (NCI Thesaurus ObjectClass-2)
C0332152 (UMLS 2011AA ObjectClass-2)
C15350 (NCI Thesaurus Property)
C0043162 (UMLS 2011AA Property)
C25382 (NCI Thesaurus Property-2)
C1521801 (UMLS 2011AA Property-2)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)

CL.36

Code List

Total body irradiation

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)

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On-Study - Primary Amyloidosis - On-Study Form - 2275605v3.0

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