Description:

RTOG 1010 Initial Evaluation Form (I1) Radiation Therapy, Paclitaxel, and Carboplatin With or Without Trastuzumab in Treating Patients With Esophageal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=86E3B1E3-58EB-2570-E040-BB89AD433A07

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=86E3B1E3-58EB-2570-E040-BB89AD433A07

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  1. 8/26/12
  2. 1/9/15
Uploaded on:

January 9, 2015

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License:
Creative Commons BY-NC 3.0 Legacy
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Adenocarcinoma of the Gastroesophageal Junction NCT01196390 On-Study - RTOG 1010 Initial Evaluation Form (I1) - 3088432v1.0

INSTRUCTIONS: All questions must be answered per code table and/or instructions. Record dates as mm-dd-yyyy unless otherwise specified

Unnamed Module 1
Amended Data
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Performance Status (Zubrod)
Kg
Oral alimentation
Nasogastric tube feeding
Ostomy feeding
Intravenous hyperalimentation
Other
Estimate of daily caloric intake
Tumor Location
Disease Extent
Clinical T Stage
Clinical N Stage
Clinical M Stage
Study Cancer
Pathologically Confirmed Primary Adenocarcinoma of the Esophagus
Cervical esophagus
Invasion into the trachea or major bronchi
Is the tumor proximal thoracic (15-24cm)
Sites of Lymphadenopathy
Celiac lymph nodes <= 2 cm (if present)
Tumor at the level of the carina
Evidence of tracheoesophageal fistule
Involvement of stomach
Involvement of stomach <= 5 cm (if present)
Baseline Lab Values (hematologic)
g/dL
mg/dL
%
%
Diagnosis Work-up
History and Physical
CT scan of the chest/abdomen/pelvis
Endoscopic biopsy of esophageal tumor
EKG
Bronchoscopy
PET/CT (Whole body)
MUGA Scan
Cardiac ECHO
Lymphadenopathy by scan (REGIONAL)
Was a surgical oncology consultation performed (DOCUMENTATING THAT THE PATIENT WILL BE ABLE TO UNDERGO CURATIVE RESECTION AFTER COMPLETION OF CHEMORADIATION)
Was a radiation oncology consultation performed (DOCUMENTING THAT THE DISEASE CAN BE ENCOMPASSED IN A RADIOTHERAPY FIELD)
Was a medical oncology consultation performed
Severe Active Comorbidity
History of Prior Malignancy (invasive)
Prior systemic chemotherapy for current study cancer
Prior radiation therapy for current study cancer
Prior radiation therapy (chest)
Prior anthracycline Treatment
Prior Taxane Therapy
Prior therapy that targeted EGFR pathway
Prior allergic reaction to study agents
History of documented congestive heart failure
Unstable angina in last 6 months
Acute bacterial or fungal infection requiring intravenous antibiotics at the time of registration
Acquired Immune Deficiency Syndrome based upon current CDC definition (AIDS)
Transmural MI in last 6 months (myocardial infarction)
Medical contraindication to esophagectomy
Is patient a woman of childbearing potential
Negative serum pregnancy test
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