ID

8501

Description

Prostate Cancer - Pathology Form - Biopsy Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=19804734-1DD7-0F92-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=19804734-1DD7-0F92-E044-0003BA3F9857

Keywords

Versions (3)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 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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Pathology - Prostate Cancer - Pathology Form - Biopsy - 2019353v3.0

English

No Instruction available.

1 forms  
  1. StudyEvent: Prostate Cancer - Pathology Form - Biopsy
    1. No Instruction available.
Crf Header
Description

Crf Header

Coordinating Group Protocol No.
Description

Protocol ID Coordinating Group

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C3274381
NCI Thesaurus ObjectClass
C25320
UMLS CUI-2
C1711341
NCI Thesaurus Property
C25462
NCI Thesaurus Property-2
C25364
Coordinating Group Code
Description

Coordinating Group Code

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS CUI-1
C1711341
NCI Thesaurus ObjectClass
C17005
UMLS CUI-2
C0805701
NCI Thesaurus ObjectClass-2
C25462
NCI Thesaurus Property
C25364
Protocol Title
Description

Protocol Title

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986303
NCI Thesaurus ObjectClass
C25320
NCI Thesaurus Property
C42774
Patient Study ID
Description

Patient Study ID

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25462
NCI Thesaurus Property-2
C25364
Institution/Affiliate
Description

Institution Name

Data type

text

Alias
NCI Thesaurus ObjectClass
C25454
UMLS CUI-1
C1301943
NCI Thesaurus ObjectClass-2
C21541
NCI Thesaurus Property
C25364
NCI Thesaurus ValueDomain
C25191
NCI Thesaurus ValueDomain-2
C21541
Other Patient ID
Description

Trial subject ID Participating Group

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C2347449
NCI Thesaurus Property
C25608
NCI Thesaurus Property-2
C25364
Participating Group Code
Description

ParticipatingGroupIdentifierCode

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
NCI Thesaurus ObjectClass
C25608
UMLS 2011AA ObjectClass
C0679823
NCI Thesaurus ObjectClass-2
C17005
UMLS 2011AA ObjectClass-2
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Name (initials acceptable)
Description

Patient Name

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1299487
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25364
Brain: Form Administration
Description

Brain: Form Administration

Person Completing Form
Description

Person Completing Form

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1550483
NCI Thesaurus ObjectClass
C25657
NCI Thesaurus Property
C25364
Are data amended (If data are amended, please circle in red when using paper form)
Description

Data amended

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C0680532
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus Property
C25416
Pathology: Prostatic Biopsy
Description

Pathology: Prostatic Biopsy

Data Source
Description

DataAnalyzedSource

Data type

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus ValueDomain
C25683
UMLS 2011AA ValueDomain
C0449416
NCI Thesaurus Property
C25420
Does analysis of tissue show evidence of therapeutic effects?
Description

SpecimenTherapeuticEffectInd-3

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C19157
UMLS 2011AA ObjectClass
C0370003
NCI Thesaurus Property
C38032
UMLS 2011AA Property
C1527144
Type of Therapy (If yes.)
Description

TherapyNameType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass
C15368
Other specify
Description

Therapy Name

Data type

text

Alias
NCI Thesaurus Property
C25364
UMLS CUI-1
C2826274
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ValueDomain
C42614
Type of Procedure
Description

ProstateSurgeryProcedure

Data type

text

Alias
NCI Thesaurus ObjectClass
C12410
UMLS 2011AA ObjectClass
C0033572
NCI Thesaurus ObjectClass-2
C15329
UMLS 2011AA ObjectClass-2
C0543467
NCI Thesaurus Property
C15368
NCI Thesaurus ValueDomain
C25218
UMLS 2011AA ValueDomain
C1948041
Other specify
Description

ProstateSurgeryProcedureSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C12410
UMLS 2011AA ObjectClass
C0033572
NCI Thesaurus ObjectClass-2
C15329
UMLS 2011AA ObjectClass-2
C0543467
NCI Thesaurus Property
C15368
Biopsy Date
Description

Biopsy Date

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C0005558
NCI Thesaurus ValueDomain-2
C25367
NCI Thesaurus ObjectClass
C15189
UMLS CUI-2
C0011008
NCI Thesaurus Property
C25275
Tumor Location, Side
Description

TumorLocation,Side

Data type

text

Tumor Location, Other Side
Description

TumorLocation,OtherSide

Data type

text

Tumor Location, Area
Description

TumorLocation,Area

Data type

text

Tumor Location, Other Area
Description

TumorLocation,OtherArea

Data type

text

Tumor Location, Zone
Description

TumorLocation,Zone

Data type

text

Biopsy, Core Length
Description

Biopsy,CoreLength

Data type

float

Biopsy, Cancer Present Measurement
Description

Biopsy,CancerPresentMeasurement

Data type

float

Biopsy, Cancer Present Percentage
Description

Biopsy,CancerPresentPercentage

Data type

float

Biopsy, Measurement of Gleason 4-5
Description

Biopsy,MeasurementofGleason4-5

Data type

float

PIN Ind, High Grade
Description

PINInd,HighGrade

Data type

text

Extraprostatic Extension Ind
Description

ExtraprostaticExtensionInd

Data type

text

Extraprostatic Extension Type
Description

ExtraprostaticExtensionType

Data type

text

Extraprostatic Extension Laterality
Description

ExtraprostaticExtensionLaterality

Data type

text

Extraprostatic Extension Extent, Vertical
Description

ExtraprostaticExtensionExtent,Vertical

Data type

float

Extraprostatic Extension Extent, Horizontal
Description

ExtraprostaticExtensionExtent,Horizontal

Data type

float

Gleason Score, Primary Pattern
Description

GleasonScore,PrimaryPattern

Data type

float

Gleason Score, Secondary Pattern
Description

GleasonScore,SecondaryPattern

Data type

float

Gleason Score, Combined
Description

GleasonScore,Combined

Data type

float

Gleason Score, Worst Pattern
Description

GleasonScore,WorstPattern

Data type

float

Pathology: Disease Assessment - Biopsy
Description

Pathology: Disease Assessment - Biopsy

Histologic Type
Description

HistologicType

Data type

text

Histologic Type, Other Name
Description

HistologicType,OtherName

Data type

text

Histologic Type, Variant
Description

HistologicType,Variant

Data type

text

Histologic Type, Other Variant
Description

HistologicType,OtherVariant

Data type

text

Histologic Type, Variant Percent
Description

HistologicType,VariantPercent

Data type

float

Histologic Type, Variant Percent
Description

HistologicType,VariantPercent

Data type

float

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1 forms
  1. StudyEvent: Prostate Cancer - Pathology Form - Biopsy
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
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)
Patient Name
Item
Patient Name (initials acceptable)
text
C25191 (NCI Thesaurus ValueDomain)
C1299487 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
Item Group
Brain: 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)
Item Group
Pathology: Prostatic Biopsy
DataAnalyzedSource
Item
Data Source
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25683 (NCI Thesaurus ValueDomain)
C0449416 (UMLS 2011AA ValueDomain)
C25420 (NCI Thesaurus Property)
Item
Does analysis of tissue show evidence of therapeutic effects?
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C0370003 (UMLS 2011AA ObjectClass)
C38032 (NCI Thesaurus Property)
C1527144 (UMLS 2011AA Property)
CL.2
Code List
Does analysis of tissue show evidence of therapeutic effects?
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)
Item
Type of Therapy (If yes.)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C15368 (NCI Thesaurus ObjectClass)
CL.3
Code List
Type of Therapy (If yes.)
CL Item
Radiation Therapy (Radiation therapy)
C15313 (NCI Thesaurus)
C1522449 (UMLS 2011AA)
CL Item
Hormonal Therapy (Hormonal therapy)
CL025695 (NCI Metathesaurus)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
Therapy Name
Item
Other specify
text
C25364 (NCI Thesaurus Property)
C2826274 (UMLS CUI-1)
C15368 (NCI Thesaurus ObjectClass)
C42614 (NCI Thesaurus ValueDomain)
Item
Type of Procedure
text
C12410 (NCI Thesaurus ObjectClass)
C0033572 (UMLS 2011AA ObjectClass)
C15329 (NCI Thesaurus ObjectClass-2)
C0543467 (UMLS 2011AA ObjectClass-2)
C15368 (NCI Thesaurus Property)
C25218 (NCI Thesaurus ValueDomain)
C1948041 (UMLS 2011AA ValueDomain)
CL.4
Code List
Type of Procedure
CL Item
Fine Needle Aspiration (Fine needle aspiration)
CL Item
Needle Biopsy (Needle biopsy)
C15190 (NCI Thesaurus)
C0936232 (UMLS 2011AA)
CL Item
Other Specify (Other)
ProstateSurgeryProcedureSpecify
Item
Other specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C12410 (NCI Thesaurus ObjectClass)
C0033572 (UMLS 2011AA ObjectClass)
C15329 (NCI Thesaurus ObjectClass-2)
C0543467 (UMLS 2011AA ObjectClass-2)
C15368 (NCI Thesaurus Property)
Biopsy Date
Item
Biopsy Date
date
C25164 (NCI Thesaurus ValueDomain)
C0005558 (UMLS CUI-1)
C25367 (NCI Thesaurus ValueDomain-2)
C15189 (NCI Thesaurus ObjectClass)
C0011008 (UMLS CUI-2)
C25275 (NCI Thesaurus Property)
Item
Tumor Location, Side
text
CL.5
Code List
Tumor Location, Side
CL Item
Left (Left)
C25229 (NCI Thesaurus)
C0205091 (UMLS 2011AA)
CL Item
Left Lateral (Left lateral)
CL Item
Midline (Midline)
C0549183 (NCI Metathesaurus)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Right (Right)
C25228 (NCI Thesaurus)
C0205090 (UMLS 2011AA)
CL Item
Right Lateral (Right lateral)
CL Item
Other, Specify (Other, specify)
TumorLocation,OtherSide
Item
Tumor Location, Other Side
text
Item
Tumor Location, Area
text
CL.6
Code List
Tumor Location, Area
CL Item
Apex (Apex)
CL Item
Base (Base)
C0178499 (NCI Metathesaurus)
CL Item
Seminal Vesicle (Seminal vesicle)
C12787 (NCI Thesaurus)
C0036628 (UMLS 2011AA)
CL Item
Other, Specify (Other, specify)
CL Item
Middle (Middle)
C25569 (NCI Thesaurus)
C0444598 (UMLS 2011AA)
TumorLocation,OtherArea
Item
Tumor Location, Other Area
text
Item
Tumor Location, Zone
text
CL.7
Code List
Tumor Location, Zone
CL Item
Not Specified (Not specified)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Transition (Transition)
C75958 (NCI Thesaurus)
C2700061 (UMLS 2011AA)
CL Item
Peripheral/central (Peripheral/central)
Biopsy,CoreLength
Item
Biopsy, Core Length
float
Biopsy,CancerPresentMeasurement
Item
Biopsy, Cancer Present Measurement
float
Biopsy,CancerPresentPercentage
Item
Biopsy, Cancer Present Percentage
float
Biopsy,MeasurementofGleason4-5
Item
Biopsy, Measurement of Gleason 4-5
float
Item
PIN Ind, High Grade
text
CL.8
Code List
PIN Ind, High Grade
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)
Item
Extraprostatic Extension Ind
text
CL.9
Code List
Extraprostatic Extension Ind
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)
Item
Extraprostatic Extension Type
text
CL.10
Code List
Extraprostatic Extension Type
CL Item
Established (Established)
C0443211 (NCI Metathesaurus)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Focal </= 2 Hpf (Focal </= 2 hpf)
Item
Extraprostatic Extension Laterality
text
CL.11
Code List
Extraprostatic Extension Laterality
CL Item
Bilateral (Bilateral)
C13332 (NCI Thesaurus)
C0238767 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Unilateral (Unilateral)
C28012 (NCI Thesaurus)
C0205092 (UMLS 2011AA)
ExtraprostaticExtensionExtent,Vertical
Item
Extraprostatic Extension Extent, Vertical
float
ExtraprostaticExtensionExtent,Horizontal
Item
Extraprostatic Extension Extent, Horizontal
float
GleasonScore,PrimaryPattern
Item
Gleason Score, Primary Pattern
float
GleasonScore,SecondaryPattern
Item
Gleason Score, Secondary Pattern
float
GleasonScore,Combined
Item
Gleason Score, Combined
float
GleasonScore,WorstPattern
Item
Gleason Score, Worst Pattern
float
Item Group
Pathology: Disease Assessment - Biopsy
Item
Histologic Type
text
CL.16
Code List
Histologic Type
CL Item
Adenocarcinoma, Conventional, Not Otherwise Specified (Adenocarcinoma, conventional, NOS)
CL Item
Urothelial Primary In Prostate (Urothelial primary in prostate)
CL Item
Adenosquamous Carcinoma (Adenosquamous carcinoma)
C3727 (NCI Thesaurus)
C0206623 (UMLS 2011AA)
CL Item
Basaloid And Adenoid Cystic Carcinoma (Basaloid and adenoid cystic carcinoma)
CL Item
Lymphoepithelioma-like Carcinoma (Lymphoepithelioma-like carcinoma)
C27387 (NCI Thesaurus)
CL Item
Mucinous (colloid) Adenocarcinoma (Mucinous (colloid) adenocarcinoma)
CL Item
Other (Other, specify)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Prostatic Duct Adenocarcinoma (Prostatic duct adenocarcinoma)
CL Item
Sarcomatoid Carcinoma (Sarcomatoid carcinoma)
C27004 (NCI Thesaurus)
C0205697 (UMLS 2011AA)
CL Item
Signet Ring Cell Carcinoma (Signet ring cell carcinoma)
C3774 (NCI Thesaurus)
C0206696 (UMLS 2011AA)
CL Item
Small Cell Carcinoma (Small cell carcinoma)
C3915 (NCI Thesaurus)
C0262584 (UMLS 2011AA)
CL Item
Squamous Cell Carcinoma (Squamous cell carcinoma)
C2929 (NCI Thesaurus)
C0007137 (UMLS 2011AA)
CL Item
Transitional Cell Carcinoma (Transitional cell carcinoma)
C2930 (NCI Thesaurus)
C0007138 (UMLS 2011AA)
CL Item
Undifferentiated Carcinoma, Not Otherwise Specified (Undifferentiated carcinoma, NOS)
CL Item
Adenocarcinoma/acinar (Adenocarcinoma/Acinar)
HistologicType,OtherName
Item
Histologic Type, Other Name
text
Item
Histologic Type, Variant
text
CL.17
Code List
Histologic Type, Variant
CL Item
Adenosquamous Carcinoma (Adenosquamous carcinoma)
C3727 (NCI Thesaurus)
C0206623 (UMLS 2011AA)
CL Item
Prostatic Duct Adenocarcinoma (Ductal carcinoma)
CL Item
Mucinous (colloid) Adenocarcinoma (Mucinous adenocarcinoma)
CL Item
Squamous Cell Carcinoma (Squamous cell carcinoma)
C2929 (NCI Thesaurus)
C0007137 (UMLS 2011AA)
CL Item
Sarcomatoid Carcinoma (Sarcomatoid carcinoma)
C27004 (NCI Thesaurus)
C0205697 (UMLS 2011AA)
CL Item
Signet Ring Cell Carcinoma (Signet ring cell carcinoma)
C3774 (NCI Thesaurus)
C0206696 (UMLS 2011AA)
CL Item
Small Cell Carcinoma (Small cell carcinoma)
C3915 (NCI Thesaurus)
C0262584 (UMLS 2011AA)
CL Item
Other, Specify (Other, specify)
HistologicType,OtherVariant
Item
Histologic Type, Other Variant
text
HistologicType,VariantPercent
Item
Histologic Type, Variant Percent
float
HistologicType,VariantPercent
Item
Histologic Type, Variant Percent
float
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