ID

8126

Description

RTOG 1016 S1: Radiation Therapy Oncology Group Phase III Head a& Neck Cancer Surgery Form Radiation Therapy With Cisplatin or Cetuximab in Treating Patients With Oropharyngeal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9A132BA5-915B-FFE2-E040-BB89AD43727A

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9A132BA5-915B-FFE2-E040-BB89AD43727A

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
Uploaded on

January 9, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Head and Neck Cancer NCT01302834 Treatment - RTOG 1016 S1: Radiation Therapy Oncology Group Phase III Head a& Neck Cancer Surgery Form - 3183854v1.0

English

INSTRUCTIONS: Submit for all patients within 2 weeks of study entry. Submit with copies of the operative report (S2) and surgical pathology report (S5). Dates are mm-dd-yyyy unless otherwise specified

1 forms  
Unnamed Module 1
Description

Unnamed Module 1

RTOG Study No.
Description

Protocol ID RTOG

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C1514695
NCI Thesaurus Property
C19778
NCI Thesaurus Property-2
C25364
Case #
Description

RadiationTherapyOncologyGroupPatientCaseIdentifierNumber

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass-2
C19778
UMLS 2011AA ObjectClass-2
C1514695
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property-2
C49152
UMLS 2011AA Property-2
C1706256
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Institution Name
Description

Institution Name

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1301943
NCI Thesaurus ObjectClass
C21541
NCI Thesaurus ValueDomain-2
C21541
NCI Thesaurus Property
C25364
Institution No.
Description

Institution Number

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C1301943
NCI Thesaurus ObjectClass
C21541
UMLS CUI-2
C0805701
NCI Thesaurus Property
C25364
Patient Initials
Description

Patient Initials

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
RTOG Patient ID
Description

Trial subject ID RTOG

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C1514695
NCI Thesaurus Property
C19778
NCI Thesaurus Property-2
C25364
Amended Data
Description

Data amended

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C0680532
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus Property
C25416
Module 2
Description

Module 2

Location of remaining disease
Description

ResidualDiseaseAnatomicalLocationText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C4809
UMLS 2011AA ObjectClass
C0543478
NCI Metathesaurus Property
C0923870
Location of remaining disease
Description

ResidualDiseaseAnatomicalLocationText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C4809
UMLS 2011AA ObjectClass
C0543478
NCI Metathesaurus Property
C0923870
Location of remaining disease
Description

ResidualDiseaseAnatomicalLocationText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C4809
UMLS 2011AA ObjectClass
C0543478
NCI Metathesaurus Property
C0923870
Primary Surgery Date
Description

PrimarySurgeryDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C25251
UMLS 2011AA ObjectClass
C0205225
NCI Thesaurus ObjectClass-2
C15329
UMLS 2011AA ObjectClass-2
C0543467
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain-2
C25367
Primary Site (Pathologic Assessment)
Description

SurgicalProcedureHeadandNeckMalignantNeoplasmResultStatus

Data type

text

Alias
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
NCI Thesaurus Property
C12418
UMLS 2011AA Property
C0460004
NCI Thesaurus Property-2
C9305
UMLS 2011AA Property-2
C0006826
NCI Thesaurus Property-3
C20200
UMLS 2011AA Property-3
C1274040
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
Primary Site (Pathologic Assessment)
Description

SurgicalProcedureHeadandNeckMalignantNeoplasmResultStatus

Data type

text

Alias
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
NCI Thesaurus Property
C12418
UMLS 2011AA Property
C0460004
NCI Thesaurus Property-2
C9305
UMLS 2011AA Property-2
C0006826
NCI Thesaurus Property-3
C20200
UMLS 2011AA Property-3
C1274040
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
Nodal surgery
Description

SurgicalProcedureHeadandNeckLymphadenectomyPerformedType

Data type

text

Alias
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
NCI Thesaurus Property
C12418
UMLS 2011AA Property
C0460004
NCI Thesaurus Property-2
C38000
UMLS 2011AA Property-2
C0884358
NCI Thesaurus Property-3
C15275
UMLS 2011AA Property-3
C0024203
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Neck nodal site right
Description

HeadandNeckRightLymphNodeNeoplasmInvolvementStatus

Data type

text

Alias
NCI Thesaurus ObjectClass
C25228
UMLS 2011AA ObjectClass
C0205090
NCI Thesaurus ObjectClass-2
C12418
UMLS 2011AA ObjectClass-2
C0460004
NCI Thesaurus ObjectClass-3
C12745
UMLS 2011AA ObjectClass-3
C0024204
NCI Thesaurus Property
C3262
UMLS 2011AA Property
C0027651
NCI Thesaurus Property-2
C25548
UMLS 2011AA Property-2
C1314939
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
Neck nodal site left
Description

HeadandNeckLeftLymphNodeNeoplasmInvolvementStatus

Data type

text

Alias
NCI Thesaurus ObjectClass
C25229
UMLS 2011AA ObjectClass
C0205091
NCI Thesaurus ObjectClass-2
C12418
UMLS 2011AA ObjectClass-2
C0460004
NCI Thesaurus ObjectClass-3
C12745
UMLS 2011AA ObjectClass-3
C0024204
NCI Thesaurus Property
C3262
UMLS 2011AA Property
C0027651
NCI Thesaurus Property-2
C25548
UMLS 2011AA Property-2
C1314939
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
Nodal Surgery Date (Left)
Description

SurgicalProcedureHeadandNeckLymphadenectomyPerformedDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
NCI Thesaurus Property
C12418
UMLS 2011AA Property
C0460004
NCI Thesaurus Property-2
C38000
UMLS 2011AA Property-2
C0884358
NCI Thesaurus Property-3
C15275
UMLS 2011AA Property-3
C0024203
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Nodal Surgery Date (Left)
Description

SurgicalProcedureHeadandNeckLymphadenectomyPerformedDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
NCI Thesaurus Property
C12418
UMLS 2011AA Property
C0460004
NCI Thesaurus Property-2
C38000
UMLS 2011AA Property-2
C0884358
NCI Thesaurus Property-3
C15275
UMLS 2011AA Property-3
C0024203
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Neck Nodal Sites (pathologic Assessment)
Description

Neck Nodal Sites (pathologic Assessment)

Location
Description

HeadandNeckLymphNodeAssessmentSite

Data type

text

Alias
NCI Thesaurus ValueDomain
C13717
UMLS 2011AA ValueDomain
C1515974
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus ObjectClass
C12418
UMLS 2011AA ObjectClass
C0460004
NCI Thesaurus ObjectClass-2
C12745
UMLS 2011AA ObjectClass-2
C0024204
Other specify (location)
Description

HeadandNeckLymphNodeRightRemovedSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus Property
C25228
UMLS 2011AA Property
C0205090
NCI Thesaurus ObjectClass
C12418
UMLS 2011AA ObjectClass
C0460004
NCI Thesaurus ObjectClass-2
C12745
UMLS 2011AA ObjectClass-2
C0024204
NCI Thesaurus Property-2
C25650
UMLS 2011AA Property-2
C0849355
Other specify (location)
Description

HeadandNeckLymphNodeLeftRemovedSpecify

Data type

text

Alias
NCI Thesaurus ObjectClass
C12418
UMLS 2011AA ObjectClass
C0460004
NCI Thesaurus ObjectClass-2
C12745
UMLS 2011AA ObjectClass-2
C0024204
NCI Thesaurus Property
C25229
UMLS 2011AA Property
C0205091
NCI Thesaurus Property-2
C25650
UMLS 2011AA Property-2
C0849355
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Number of Positive Lymph Nodes
Description

LymphNodePositiveCount

Data type

float

Alias
NCI Thesaurus Property
C25246
UMLS 2011AA Property
C1446409
NCI Thesaurus ObjectClass
C12745
UMLS 2011AA ObjectClass
C0024204
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
Number of Lymph Nodes Examined
Description

LymphNodeExaminedCount

Data type

float

Alias
NCI Thesaurus Property
C25500
UMLS 2011AA Property
C0332128
NCI Thesaurus ObjectClass
C12745
UMLS 2011AA ObjectClass
C0024204
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
Extracapsular Extension?
Description

DiseaseExtracapsularExtensionInd-3

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C25270
UMLS 2011AA Property
C0231448
Total Nodes Positive Right
Description

RightLymphNodePositiveTotalCount

Data type

float

Alias
NCI Thesaurus ObjectClass
C25228
UMLS 2011AA ObjectClass
C0205090
NCI Thesaurus ObjectClass-2
C12745
UMLS 2011AA ObjectClass-2
C0024204
NCI Thesaurus Property
C25246
UMLS 2011AA Property
C1446409
NCI Thesaurus ValueDomain
C25304
UMLS 2011AA ValueDomain
C0439810
NCI Thesaurus ValueDomain-2
C25463
UMLS 2011AA ValueDomain-2
C0750480
Total Nodes Examined Right
Description

RightLymphNodeExaminedTotalCount

Data type

float

Alias
NCI Thesaurus ObjectClass
C25228
UMLS 2011AA ObjectClass
C0205090
NCI Thesaurus ObjectClass-2
C12745
UMLS 2011AA ObjectClass-2
C0024204
NCI Thesaurus Property
C25500
UMLS 2011AA Property
C0332128
NCI Thesaurus ValueDomain
C25304
UMLS 2011AA ValueDomain
C0439810
NCI Thesaurus ValueDomain-2
C25463
UMLS 2011AA ValueDomain-2
C0750480
Total Nodes Positive Left
Description

LeftLymphNodePositiveTotalCount

Data type

float

Alias
NCI Thesaurus ObjectClass
C25229
UMLS 2011AA ObjectClass
C0205091
NCI Thesaurus ObjectClass-2
C12745
UMLS 2011AA ObjectClass-2
C0024204
NCI Thesaurus Property
C25246
UMLS 2011AA Property
C1446409
NCI Thesaurus ValueDomain
C25304
UMLS 2011AA ValueDomain
C0439810
NCI Thesaurus ValueDomain-2
C25463
UMLS 2011AA ValueDomain-2
C0750480
Total Nodes Examined Left
Description

LeftLymphNodeExaminedTotalCount

Data type

float

Alias
NCI Thesaurus ObjectClass
C25229
UMLS 2011AA ObjectClass
C0205091
NCI Thesaurus ObjectClass-2
C12745
UMLS 2011AA ObjectClass-2
C0024204
NCI Thesaurus Property
C25500
UMLS 2011AA Property
C0332128
NCI Thesaurus ValueDomain
C25304
UMLS 2011AA ValueDomain
C0439810
NCI Thesaurus ValueDomain-2
C25463
UMLS 2011AA ValueDomain-2
C0750480
Was tumor present in the soft tissue of the neck without an identifiable lymph node present?
Description

HeadandNeckConnectiveTissueNeoplasmWithoutLymphNodePresentIndicator

Data type

text

Alias
NCI Thesaurus ObjectClass
C3262
UMLS 2011AA ObjectClass
C0027651
NCI Thesaurus ObjectClass-2
C12418
UMLS 2011AA ObjectClass-2
C0460004
NCI Thesaurus ObjectClass-3
C12374
UMLS 2011AA ObjectClass-3
C0009780
NCI Thesaurus Property
C25626
UMLS 2011AA Property
C0150312
NCI Thesaurus Property-2
C12745
UMLS 2011AA Property-2
C0024204
NCI Thesaurus Property-3
C25718
UMLS 2011AA Property-3
C0332288
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Yes specify level
Description

HeadandNeckConnectiveTissueNeoplasmWithoutLymphNodePresentSpecify

Data type

text

Alias
NCI Thesaurus ObjectClass
C3262
UMLS 2011AA ObjectClass
C0027651
NCI Thesaurus ObjectClass-2
C12418
UMLS 2011AA ObjectClass-2
C0460004
NCI Thesaurus ObjectClass-3
C12374
UMLS 2011AA ObjectClass-3
C0009780
NCI Thesaurus Property
C25626
UMLS 2011AA Property
C0150312
NCI Thesaurus Property-2
C12745
UMLS 2011AA Property-2
C0024204
NCI Thesaurus Property-3
C25718
UMLS 2011AA Property-3
C0332288
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Footer Module
Description

Footer Module

Comments
Description

Research Comments

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C0947611
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
Signature of Person Completing This Form
Description

Responsible Person Signature

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C1550483
NCI Thesaurus ObjectClass
C25190
NCI Thesaurus ObjectClass-2
C25657
NCI Thesaurus Property
C25678
Form Completion Date, Original
Description

Form Completion Date

Data type

date

Alias
NCI Thesaurus ObjectClass
C19464
UMLS CUI-1
C1549507
NCI Thesaurus Property
C25250
NCI Thesaurus Property-2
C25604
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25367
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INSTRUCTIONS: Submit for all patients within 2 weeks of study entry. Submit with copies of the operative report (S2) and surgical pathology report (S5). Dates are mm-dd-yyyy unless otherwise specified

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed Module 1
Protocol ID RTOG
Item
RTOG Study No.
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1514695 (UMLS CUI-2)
C19778 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
RadiationTherapyOncologyGroupPatientCaseIdentifierNumber
Item
Case #
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C19778 (NCI Thesaurus ObjectClass-2)
C1514695 (UMLS 2011AA ObjectClass-2)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C49152 (NCI Thesaurus Property-2)
C1706256 (UMLS 2011AA Property-2)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
Institution Name
Item
Institution Name
text
C25191 (NCI Thesaurus ValueDomain)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C21541 (NCI Thesaurus ValueDomain-2)
C25364 (NCI Thesaurus Property)
Institution Number
Item
Institution No.
text
C25337 (NCI Thesaurus ValueDomain)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C0805701 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
Patient Initials
Item
Patient Initials
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Trial subject ID RTOG
Item
RTOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1514695 (UMLS CUI-2)
C19778 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Data amended
Item
Amended Data
boolean
C38148 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
Item Group
Module 2
ResidualDiseaseAnatomicalLocationText
Item
Location of remaining disease
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C4809 (NCI Thesaurus ObjectClass)
C0543478 (UMLS 2011AA ObjectClass)
C0923870 (NCI Metathesaurus Property)
ResidualDiseaseAnatomicalLocationText
Item
Location of remaining disease
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C4809 (NCI Thesaurus ObjectClass)
C0543478 (UMLS 2011AA ObjectClass)
C0923870 (NCI Metathesaurus Property)
ResidualDiseaseAnatomicalLocationText
Item
Location of remaining disease
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C4809 (NCI Thesaurus ObjectClass)
C0543478 (UMLS 2011AA ObjectClass)
C0923870 (NCI Metathesaurus Property)
PrimarySurgeryDate
Item
Primary Surgery Date
date
C25251 (NCI Thesaurus ObjectClass)
C0205225 (UMLS 2011AA ObjectClass)
C15329 (NCI Thesaurus ObjectClass-2)
C0543467 (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)
Item
Primary Site (Pathologic Assessment)
text
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C12418 (NCI Thesaurus Property)
C0460004 (UMLS 2011AA Property)
C9305 (NCI Thesaurus Property-2)
C0006826 (UMLS 2011AA Property-2)
C20200 (NCI Thesaurus Property-3)
C1274040 (UMLS 2011AA Property-3)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
CL.3
Code List
Primary Site (Pathologic Assessment)
CL Item
No Tumor Demonstrable On Final Pathology Specimen (No tumor demonstrable on final pathology specimen)
CL Item
Not Operated (Not operated)
CL Item
Tumor Present All Margins Clear On Final Pathology Specimen (Tumor present all margins clear on final pathology specimen)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Tumor Present, Margin Involved On Final Specimen (Tumor present margin involved on final pathology specimen)
Item
Primary Site (Pathologic Assessment)
text
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C12418 (NCI Thesaurus Property)
C0460004 (UMLS 2011AA Property)
C9305 (NCI Thesaurus Property-2)
C0006826 (UMLS 2011AA Property-2)
C20200 (NCI Thesaurus Property-3)
C1274040 (UMLS 2011AA Property-3)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
CL.3
Code List
Primary Site (Pathologic Assessment)
CL Item
No Tumor Demonstrable On Final Pathology Specimen (No tumor demonstrable on final pathology specimen)
CL Item
Not Operated (Not operated)
CL Item
Tumor Present All Margins Clear On Final Pathology Specimen (Tumor present all margins clear on final pathology specimen)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Tumor Present, Margin Involved On Final Specimen (Tumor present margin involved on final pathology specimen)
Item
Nodal surgery
text
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C12418 (NCI Thesaurus Property)
C0460004 (UMLS 2011AA Property)
C38000 (NCI Thesaurus Property-2)
C0884358 (UMLS 2011AA Property-2)
C15275 (NCI Thesaurus Property-3)
C0024203 (UMLS 2011AA Property-3)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.4
Code List
Nodal surgery
CL Item
Bilateral Node Dissection (Bilateral node dissection)
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Unilateral Lymph Node Dissection Left (Unilateral node dissection (left))
CL Item
Unilateral Lymph Node Dissection Right (Unilateral node dissection (right))
Item
Neck nodal site right
text
C25228 (NCI Thesaurus ObjectClass)
C0205090 (UMLS 2011AA ObjectClass)
C12418 (NCI Thesaurus ObjectClass-2)
C0460004 (UMLS 2011AA ObjectClass-2)
C12745 (NCI Thesaurus ObjectClass-3)
C0024204 (UMLS 2011AA ObjectClass-3)
C3262 (NCI Thesaurus Property)
C0027651 (UMLS 2011AA Property)
C25548 (NCI Thesaurus Property-2)
C1314939 (UMLS 2011AA Property-2)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
CL.5
Code List
Neck nodal site right
CL Item
Complete Resection Of All Gross Tumor (Complete resection of all gross disease)
CL Item
Incomplete/partial Resection Of Gross Tumor (Incomplete/partial resection of gross tumor)
CL Item
Not Operated (Not operated)
Item
Neck nodal site left
text
C25229 (NCI Thesaurus ObjectClass)
C0205091 (UMLS 2011AA ObjectClass)
C12418 (NCI Thesaurus ObjectClass-2)
C0460004 (UMLS 2011AA ObjectClass-2)
C12745 (NCI Thesaurus ObjectClass-3)
C0024204 (UMLS 2011AA ObjectClass-3)
C3262 (NCI Thesaurus Property)
C0027651 (UMLS 2011AA Property)
C25548 (NCI Thesaurus Property-2)
C1314939 (UMLS 2011AA Property-2)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
CL.6
Code List
Neck nodal site left
CL Item
Complete Resection Of All Gross Tumor (Complete resection of all gross disease)
CL Item
Incomplete/partial Resection Of Gross Tumor (Incomplete/partial resection of gross tumor)
CL Item
Not Operated (Not operated)
SurgicalProcedureHeadandNeckLymphadenectomyPerformedDate
Item
Nodal Surgery Date (Left)
date
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C12418 (NCI Thesaurus Property)
C0460004 (UMLS 2011AA Property)
C38000 (NCI Thesaurus Property-2)
C0884358 (UMLS 2011AA Property-2)
C15275 (NCI Thesaurus Property-3)
C0024203 (UMLS 2011AA Property-3)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
SurgicalProcedureHeadandNeckLymphadenectomyPerformedDate
Item
Nodal Surgery Date (Left)
date
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C12418 (NCI Thesaurus Property)
C0460004 (UMLS 2011AA Property)
C38000 (NCI Thesaurus Property-2)
C0884358 (UMLS 2011AA Property-2)
C15275 (NCI Thesaurus Property-3)
C0024203 (UMLS 2011AA Property-3)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item Group
Neck Nodal Sites (pathologic Assessment)
Item
Location
text
C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C12418 (NCI Thesaurus ObjectClass)
C0460004 (UMLS 2011AA ObjectClass)
C12745 (NCI Thesaurus ObjectClass-2)
C0024204 (UMLS 2011AA ObjectClass-2)
CL.7
Code List
Location
CL Item
Left - Level I (submandibular) (Left - Level I (Submandibular))
CL Item
Left - Level Ii (upper 1/3 Internal Jugular) (Left - Level II (Upper 1/3 Internal Jugular))
CL Item
Left - Level Iii (mid 1/3 Internal Jugular) (Left - Level III (Mid 1/3 Internal Jugular))
CL Item
Left - Level Iv (lower 1/3 Internal Jugular) (Left - Level IV (Lower 1/3 Internal Jugular))
CL Item
Left - Level V (posterior Triangle) (Left - Level V (Posterior Triangle))
CL Item
Left - Other (Left - Other specify)
CL Item
Right - Level I (submandibular) (Right - Level I (Submandibular))
CL Item
Right - Level Ii (upper 1/3 Internal Jugular) (Right - Level II (Upper 1/3 Internal Jugular))
CL Item
Right - Level Iii (mid 1/3 Internal Jugular) (Right - Level III (Mid 1/3 Internal Jugular))
CL Item
Right - Level Iv (lower 1/3 Internal Jugular) (Right - Level IV (Lower 1/3 Internal Jugular))
CL Item
Right - Level V (posterior Triangle) (Right - Level V (Posterior Triangle))
CL Item
Right - Other (Right - Other specify)
HeadandNeckLymphNodeRightRemovedSpecify
Item
Other specify (location)
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25228 (NCI Thesaurus Property)
C0205090 (UMLS 2011AA Property)
C12418 (NCI Thesaurus ObjectClass)
C0460004 (UMLS 2011AA ObjectClass)
C12745 (NCI Thesaurus ObjectClass-2)
C0024204 (UMLS 2011AA ObjectClass-2)
C25650 (NCI Thesaurus Property-2)
C0849355 (UMLS 2011AA Property-2)
HeadandNeckLymphNodeLeftRemovedSpecify
Item
Other specify (location)
text
C12418 (NCI Thesaurus ObjectClass)
C0460004 (UMLS 2011AA ObjectClass)
C12745 (NCI Thesaurus ObjectClass-2)
C0024204 (UMLS 2011AA ObjectClass-2)
C25229 (NCI Thesaurus Property)
C0205091 (UMLS 2011AA Property)
C25650 (NCI Thesaurus Property-2)
C0849355 (UMLS 2011AA Property-2)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
LymphNodePositiveCount
Item
Number of Positive Lymph Nodes
float
C25246 (NCI Thesaurus Property)
C1446409 (UMLS 2011AA Property)
C12745 (NCI Thesaurus ObjectClass)
C0024204 (UMLS 2011AA ObjectClass)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
LymphNodeExaminedCount
Item
Number of Lymph Nodes Examined
float
C25500 (NCI Thesaurus Property)
C0332128 (UMLS 2011AA Property)
C12745 (NCI Thesaurus ObjectClass)
C0024204 (UMLS 2011AA ObjectClass)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
Item
Extracapsular Extension?
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25270 (NCI Thesaurus Property)
C0231448 (UMLS 2011AA Property)
CL.8
Code List
Extracapsular Extension?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
RightLymphNodePositiveTotalCount
Item
Total Nodes Positive Right
float
C25228 (NCI Thesaurus ObjectClass)
C0205090 (UMLS 2011AA ObjectClass)
C12745 (NCI Thesaurus ObjectClass-2)
C0024204 (UMLS 2011AA ObjectClass-2)
C25246 (NCI Thesaurus Property)
C1446409 (UMLS 2011AA Property)
C25304 (NCI Thesaurus ValueDomain)
C0439810 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C0750480 (UMLS 2011AA ValueDomain-2)
RightLymphNodeExaminedTotalCount
Item
Total Nodes Examined Right
float
C25228 (NCI Thesaurus ObjectClass)
C0205090 (UMLS 2011AA ObjectClass)
C12745 (NCI Thesaurus ObjectClass-2)
C0024204 (UMLS 2011AA ObjectClass-2)
C25500 (NCI Thesaurus Property)
C0332128 (UMLS 2011AA Property)
C25304 (NCI Thesaurus ValueDomain)
C0439810 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C0750480 (UMLS 2011AA ValueDomain-2)
LeftLymphNodePositiveTotalCount
Item
Total Nodes Positive Left
float
C25229 (NCI Thesaurus ObjectClass)
C0205091 (UMLS 2011AA ObjectClass)
C12745 (NCI Thesaurus ObjectClass-2)
C0024204 (UMLS 2011AA ObjectClass-2)
C25246 (NCI Thesaurus Property)
C1446409 (UMLS 2011AA Property)
C25304 (NCI Thesaurus ValueDomain)
C0439810 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C0750480 (UMLS 2011AA ValueDomain-2)
LeftLymphNodeExaminedTotalCount
Item
Total Nodes Examined Left
float
C25229 (NCI Thesaurus ObjectClass)
C0205091 (UMLS 2011AA ObjectClass)
C12745 (NCI Thesaurus ObjectClass-2)
C0024204 (UMLS 2011AA ObjectClass-2)
C25500 (NCI Thesaurus Property)
C0332128 (UMLS 2011AA Property)
C25304 (NCI Thesaurus ValueDomain)
C0439810 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C0750480 (UMLS 2011AA ValueDomain-2)
Item
Was tumor present in the soft tissue of the neck without an identifiable lymph node present?
text
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C12418 (NCI Thesaurus ObjectClass-2)
C0460004 (UMLS 2011AA ObjectClass-2)
C12374 (NCI Thesaurus ObjectClass-3)
C0009780 (UMLS 2011AA ObjectClass-3)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C12745 (NCI Thesaurus Property-2)
C0024204 (UMLS 2011AA Property-2)
C25718 (NCI Thesaurus Property-3)
C0332288 (UMLS 2011AA Property-3)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.9
Code List
Was tumor present in the soft tissue of the neck without an identifiable lymph node present?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Not Operated (Not operated)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
HeadandNeckConnectiveTissueNeoplasmWithoutLymphNodePresentSpecify
Item
Yes specify level
text
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C12418 (NCI Thesaurus ObjectClass-2)
C0460004 (UMLS 2011AA ObjectClass-2)
C12374 (NCI Thesaurus ObjectClass-3)
C0009780 (UMLS 2011AA ObjectClass-3)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C12745 (NCI Thesaurus Property-2)
C0024204 (UMLS 2011AA Property-2)
C25718 (NCI Thesaurus Property-3)
C0332288 (UMLS 2011AA Property-3)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item Group
Footer Module
Research Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
Responsible Person Signature
Item
Signature of Person Completing This Form
text
C25704 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25190 (NCI Thesaurus ObjectClass)
C25657 (NCI Thesaurus ObjectClass-2)
C25678 (NCI Thesaurus Property)
Form Completion Date
Item
Form Completion Date, Original
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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