Beschreibung:

RTOG 1010 Initial Follow-up Form (FS) 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=86E1F1DA-E438-F1B2-E040-BB89AD43175C

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=86E1F1DA-E438-F1B2-E040-BB89AD43175C

Stichworte:

Klinische Studie [Dokumenttyp]

Ösophagus

Verlaufsstudien

Versionen (3) ▾

26.08.12
09.01.15
09.01.15

Hochgeladen am:

9. Januar 2015

DOI:

Keine DOI zugewiesen. Für eine Beantragung loggen Sie sich ein.

Lizenz:

Creative Commons BY-NC 3.0 Legacy

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Adenocarcinoma of the Gastroesophageal Junction NCT01196390 Follow-Up - RTOG 1010 Initial Follow-up Form (FS) - 3088118v1.0

Details

INSTRUCTIONS: Submit this form at the appropriate follow-up interval and whenever there is a change in the patient's status. Dates are recorded mm-dd-yyyy unless otherwise specified

StudyEvent: RTOG 1010 Initial Follow-up Form (FS)
1. INSTRUCTIONS: Submit this form at the appropriate follow-up interval and whenever there is a change in the patient's status. Dates are recorded mm-dd-yyyy unless otherwise specified

Unnamed Module 1

RTOG Study No.

Case #

Institution Name

Institution No.

Patient Initials

RTOG Patient ID

Amended Data

Yes

Events

Event

Complete Response (Complete response)

Recurrence (Recurrence)

Progression Of Local Disease (Progression of local disease)

Recurrence Of Nodal Disease (Recurrence of nodal disease)

Nodal Progression (Nodal progression)

10 weitere Items in der Detailansicht.

Date (mm-dd-yyyy)

Specify

Toxicities

Grade 3 or 4 Restrictive Cardiomyopathy

Yes

Toxicities

Was a MUGA/Echocardiogram Performed During This Report Period

Yes

Incipient CHF (If yes, did the patient experience defined as asymptomatic >20% decrease in LVEF or a decrease of LVEF >10% below the institutions lower limit of normal and required treatment according to institutional guidelines)

Yes

LVEF Status (If a MUGA/echocardiogram was performed during this report period)

Decrease Of 10-15% From Baseline And 1-5% Below Lln (Decrease of 10-15% from baseline and 1-5% below LLN)

Decrease Of 10-15% From Baseline And >=6% Below Lln (Decrease of 10-15% from baseline and >=6% below LLN)

Decrease Of <10% From Baseline And 1-5% Below Lln (Decrease of <10% from baseline and 1-5% below LLN)

Decrease Of <10% From Baseline And >=6% Below Lln (Decrease of <10% from baseline and >=6% below LLN)

Decrease Of >=16% From Baseline And 1-5% Below Lln (Decrease of >=16% from baseline and 1-5% below LLN)

3 weitere Items in der Detailansicht.

Footer Module

Comments

Investigator Signature

Date

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