ID

8052

Beschreibung

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

Stichworte

Diagnostik, bildgebende

19.09.12 19.09.12 -
09.01.15 09.01.15 - Martin Dugas
30.03.15 30.03.15 - Martin Dugas

Hochgeladen am

9. Januar 2015

DOI

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Lizenz

Creative Commons BY-NC 3.0 Legacy

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

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Details

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 Formulare

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

Typ

Description | Question | Decode (Coded Value)

Datentyp

Alias

Header

Item Group

Header

Form ID CALGB

Item

CALGB Form

text

C25337 (NCI Thesaurus ValueDomain)
C3262252 (UMLS CUI-1)
C19464 (NCI Thesaurus ObjectClass)
C1516238 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25442 (NCI Thesaurus ObjectClass-2)

Protocol ID CALGB

Item

CALGB Study No

text

C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1516238 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25442 (NCI Thesaurus Property-2)

Trial subject ID CALGB

Item

CALGB Patient ID

text

C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1516238 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25442 (NCI Thesaurus Property-2)

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-2)
C0348026 (UMLS 2011AA ObjectClass-2)

Data amended

Item

Are data amended

boolean

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

Unnamed2

Item Group

Unnamed2

Patient Initials

Item

Patient Initials (Last, First Middle)

text

C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)

Medical Record Number

Item

Patient Hospital No.

text

C25337 (NCI Thesaurus ValueDomain)
C1301894 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25261 (NCI Thesaurus Property)
C25198 (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)

Participating Group

Item

Participating Group

text

C25191 (NCI Thesaurus ValueDomain)
C2347449 (UMLS CUI-1)
C25608 (NCI Thesaurus ObjectClass)
C17005 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)

Study Number Participating Group

Item

Participating Group Study No.

text

C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)

Trial subject ID Participating Group

Item

Participating Group 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)

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-2)
C1522326 (UMLS 2011AA ObjectClass-2)

Technique Factors

Item Group

Technique Factors

ChestComputedTomographyKilovoltPeakMeasurement

Item

KVp

float

C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)
C17204 (NCI Thesaurus ObjectClass)
C0040405 (UMLS 2011AA ObjectClass)
C25389 (NCI Thesaurus ObjectClass-2)
C0817096 (UMLS 2011AA ObjectClass-2)
C48432 (NCI Thesaurus Property)
C1708610 (UMLS 2011AA Property)

ChestComputedTomographyPitchMeasurement

Item

Pitch

float

C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)
C17204 (NCI Thesaurus ObjectClass)
C0040405 (UMLS 2011AA ObjectClass)
C25389 (NCI Thesaurus ObjectClass-2)
C0817096 (UMLS 2011AA ObjectClass-2)
C48442 (NCI Thesaurus Property)
C1704634 (UMLS 2011AA Property)

ChestComputedTomographyAmpereMeasurement

Item

float

ChestComputedTomographyScanLengthMeasurement

Item

Scan Length (craniocaudal extent)

float

C17204 (NCI Thesaurus ObjectClass)
C0040405 (UMLS 2011AA ObjectClass)
C25389 (NCI Thesaurus ObjectClass-2)
C0817096 (UMLS 2011AA ObjectClass-2)
C17999 (NCI Thesaurus Property)
C0441633 (UMLS 2011AA Property)
C25334 (NCI Thesaurus Property-2)
C1444754 (UMLS 2011AA Property-2)
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)

ChestComputedTomographyRevolutionTimeMeasurement

Item

Rotation Time

float

C17204 (NCI Thesaurus ObjectClass)
C0040405 (UMLS 2011AA ObjectClass)
C25389 (NCI Thesaurus ObjectClass-2)
C0817096 (UMLS 2011AA ObjectClass-2)
C25207 (NCI Thesaurus Property)
C0040223 (UMLS 2011AA Property)
C48439 (NCI Thesaurus Property-2)
C0035868 (UMLS 2011AA Property-2)
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-2)
C0205146 (UMLS 2011AA Property-2)

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-2)
C1707511 (UMLS 2011AA ObjectClass-2)
C25235 (NCI Thesaurus ObjectClass-3)
C1282910 (UMLS 2011AA ObjectClass-3)
C25258 (NCI Thesaurus ObjectClass-4)
C0205393 (UMLS 2011AA ObjectClass-4)
C12468 (NCI Thesaurus Property)
C0024109 (UMLS 2011AA Property)
C38000 (NCI Thesaurus Property-2)
C0884358 (UMLS 2011AA Property-2)
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-2)
C1707511 (UMLS 2011AA ObjectClass-2)
C25235 (NCI Thesaurus ObjectClass-3)
C1282910 (UMLS 2011AA ObjectClass-3)
C25258 (NCI Thesaurus ObjectClass-4)
C0205393 (UMLS 2011AA ObjectClass-4)
C12702 (NCI Thesaurus Property)
C0011980 (UMLS 2011AA Property)
C38000 (NCI Thesaurus Property-2)
C0884358 (UMLS 2011AA Property-2)
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-2)
C1522427 (UMLS 2011AA ObjectClass-2)
C44465 (NCI Thesaurus ObjectClass-3)
C1707511 (UMLS 2011AA ObjectClass-3)
C3262 (NCI Thesaurus Property)
C0027651 (UMLS 2011AA Property)
C38000 (NCI Thesaurus Property-2)
C0884358 (UMLS 2011AA Property-2)
C25445 (NCI Thesaurus Property-3)
C0205099 (UMLS 2011AA Property-3)
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-2)
C1522427 (UMLS 2011AA ObjectClass-2)
C44465 (NCI Thesaurus ObjectClass-3)
C1707511 (UMLS 2011AA ObjectClass-3)
C0549183 (NCI Metathesaurus Property)
C25445 (NCI Thesaurus Property)
C0205099 (UMLS 2011AA Property)
C25334 (NCI Thesaurus Property-2)
C1444754 (UMLS 2011AA Property-2)
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-2)
C1707511 (UMLS 2011AA ObjectClass-2)
C12468 (NCI Thesaurus Property)
C0024109 (UMLS 2011AA Property)
C25231 (NCI Thesaurus Property-2)
C0205094 (UMLS 2011AA Property-2)
C25622 (NCI Thesaurus Property-3)
C0205095 (UMLS 2011AA Property-3)
C25334 (NCI Thesaurus Property-4)
C1444754 (UMLS 2011AA Property-4)
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-2)
C1707511 (UMLS 2011AA ObjectClass-2)
C12468 (NCI Thesaurus Property)
C0024109 (UMLS 2011AA Property)
C25622 (NCI Thesaurus Property-2)
C0205095 (UMLS 2011AA Property-2)
C25445 (NCI Thesaurus Property-3)
C0205099 (UMLS 2011AA Property-3)
C25334 (NCI Thesaurus Property-4)
C1444754 (UMLS 2011AA Property-4)
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-2)
C0040405 (UMLS 2011AA ObjectClass-2)
C25389 (NCI Thesaurus ObjectClass-3)
C0817096 (UMLS 2011AA ObjectClass-3)
C25285 (NCI Thesaurus Property)
C1301886 (UMLS 2011AA Property)
C25564 (NCI Thesaurus Property-2)
C0806909 (UMLS 2011AA Property-2)
C25334 (NCI Thesaurus Property-3)
C1444754 (UMLS 2011AA Property-3)
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-2)
C0040405 (UMLS 2011AA ObjectClass-2)
C25389 (NCI Thesaurus ObjectClass-3)
C0817096 (UMLS 2011AA ObjectClass-3)
C12664 (NCI Thesaurus ObjectClass-4)
C0230168 (UMLS 2011AA ObjectClass-4)
C25285 (NCI Thesaurus Property)
C1301886 (UMLS 2011AA Property)
C25564 (NCI Thesaurus Property-2)
C0806909 (UMLS 2011AA Property-2)
C25334 (NCI Thesaurus Property-3)
C1444754 (UMLS 2011AA Property-3)
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

boolean

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)

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)

float

C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C25285 (NCI Thesaurus Property)
C1301886 (UMLS 2011AA Property)
C25629 (NCI Thesaurus Property-2)
C0332152 (UMLS 2011AA Property-2)
C25564 (NCI Thesaurus Property-3)
C0806909 (UMLS 2011AA Property-3)
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-2)
C0817096 (UMLS 2011AA ObjectClass-2)
C25629 (NCI Thesaurus ObjectClass-3)
C0332152 (UMLS 2011AA ObjectClass-3)
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-2)
C0040405 (UMLS 2011AA ObjectClass-2)
C25389 (NCI Thesaurus ObjectClass-3)
C0817096 (UMLS 2011AA ObjectClass-3)
C12664 (NCI Thesaurus ObjectClass-4)
C0230168 (UMLS 2011AA ObjectClass-4)
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-2)
C0040405 (UMLS 2011AA ObjectClass-2)
C25389 (NCI Thesaurus ObjectClass-3)
C0817096 (UMLS 2011AA ObjectClass-3)
C12664 (NCI Thesaurus ObjectClass-4)
C0230168 (UMLS 2011AA ObjectClass-4)
C25377 (NCI Thesaurus Property)
C0700364 (UMLS 2011AA Property)
C43290 (NCI Thesaurus Property-2)
C1711375 (UMLS 2011AA Property-2)
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-2)
C0024204 (UMLS 2011AA ObjectClass-2)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C3399 (NCI Thesaurus Property-2)
C0038999 (UMLS 2011AA Property-2)
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

boolean

C17007 (NCI Thesaurus ObjectClass)
C0032743 (UMLS 2011AA ObjectClass)
C25629 (NCI Thesaurus ObjectClass-2)
C0332152 (UMLS 2011AA ObjectClass-2)
C15368 (NCI Thesaurus ObjectClass-3)
C25429 (NCI Thesaurus Property)
C0470187 (UMLS 2011AA Property)
C41255 (NCI Thesaurus Property-2)
C0459471 (UMLS 2011AA Property-2)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)

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-2)
C0817096 (UMLS 2011AA Property-2)
C25171 (NCI Thesaurus Property-3)
C0013893 (UMLS 2011AA Property-3)
C38010 (NCI Thesaurus Property-4)
C1527048 (UMLS 2011AA Property-4)
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-2)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C3200 (NCI Thesaurus Property-2)
C0020445 (UMLS 2011AA Property-2)
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-2)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C3200 (NCI Thesaurus Property-2)
C0020445 (UMLS 2011AA Property-2)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)

StandardUptakeValuePositronEmissionTomographyAssessmentMaximumMeasurement

Item

SUV Max

float

C17007 (NCI Thesaurus ObjectClass)
C0032743 (UMLS 2011AA ObjectClass)
C44275 (NCI Thesaurus ObjectClass-2)
C1442989 (UMLS 2011AA ObjectClass-2)
C0243144 (NCI Metathesaurus ObjectClass)
C25712 (NCI Thesaurus ObjectClass-3)
C1522609 (UMLS 2011AA ObjectClass-3)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)
C25564 (NCI Thesaurus ValueDomain-2)
C0806909 (UMLS 2011AA ValueDomain-2)

StandardUptakeValuePositronEmissionTomographyAssessmentMeanMeasurement

Item

SUV Mean

float

C17007 (NCI Thesaurus ObjectClass)
C0032743 (UMLS 2011AA ObjectClass)
C44275 (NCI Thesaurus ObjectClass-2)
C1442989 (UMLS 2011AA ObjectClass-2)
C0243144 (NCI Metathesaurus ObjectClass)
C25712 (NCI Thesaurus ObjectClass-3)
C1522609 (UMLS 2011AA ObjectClass-3)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)
C53319 (NCI Thesaurus ValueDomain-2)
C0444504 (UMLS 2011AA ValueDomain-2)

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-2)
C0024109 (UMLS 2011AA Property-2)
C18206 (NCI Thesaurus Property-3)
C1269798 (UMLS 2011AA Property-3)
C38000 (NCI Thesaurus Property-4)
C0884358 (UMLS 2011AA Property-4)
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)

Footer

Item Group

Footer

Person Completing Form

Item

Completed by (Last name, First name)

text

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

Form Completion Date

Item

Date Form Originally Completed

date

C19464 (NCI Thesaurus ObjectClass)
C1549507 (UMLS CUI-1)
C25250 (NCI Thesaurus Property)
C25604 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)

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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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