INSTRUCTIONS: Complete this form at the end of each cycle (1 cycle = 3 weeks), and at required follow-ups if specified by the Long-Term Follow-Up Form (to report late adverse events).

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
Protocol Number ECOG
Item
ECOG Protocol Number
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1512162 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25491 (NCI Thesaurus Property-2)
Generic drug form
Item
DCI Name
text
C25191 (NCI Thesaurus ValueDomain)
C3242750 (UMLS CUI-1)
C19464 (NCI Thesaurus Property)
C25474 (NCI Thesaurus ObjectClass)
C25452 (NCI Thesaurus ObjectClass-2)
Registration Number
Item
Registration Step
text
C25337 (NCI Thesaurus ValueDomain)
C1514821 (UMLS CUI-1)
C25646 (NCI Thesaurus ObjectClass)
C0237753 (UMLS CUI-2)
C16154 (NCI Thesaurus Property)
C16154 (NCI Thesaurus ValueDomain-2)
Item
Reporting Period
text
C25284 (NCI Thesaurus ValueDomain)
C2347804 (UMLS CUI-1)
C25214 (NCI Thesaurus ObjectClass)
C25616 (NCI Thesaurus Property)
C25651 (NCI Thesaurus ObjectClass-2)
CL.1
Code List
Reporting Period
CL Item
Baseline (Baseline)
C25213 (NCI Thesaurus)
C1442488 (UMLS 2011AA)
Study Number Participating Group
Item
Participating Group Protocol Number
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)
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)
Item Group
Data amendment
Data amended
Item
Please mark an 'X' if data have been amended
text
C25704 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
Data amended date
Item
Date data amended
date
C25164 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C0011008 (UMLS CUI-2)
C25416 (NCI Thesaurus Property)
C25367 (NCI Thesaurus ValueDomain-2)
Item Group
Patient demographics
Patient ID ECOG
Item
ECOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1512162 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25491 (NCI Thesaurus Property-2)
Item
ECOG Performance Status (Prior to Surgery)
text
C25664 (NCI Thesaurus ValueDomain)
C1520224 (UMLS CUI-1)
C25367 (NCI Thesaurus Property)
C25491 (NCI Thesaurus ValueDomain-2)
C20641 (NCI Thesaurus ObjectClass)
CL.2
Code List
ECOG Performance Status (Prior to Surgery)
CL Item
Fully Active, Able To Carry On All Pre-disease Performance Without Restriction. (0)
CL Item
Restricted In Physically Strenuous Activity But Ambulatory And Able To Carry Out Work Of A Light Or Sedentary Nature, E.g., Light Housework, Office Work. (1)
CL Item
Ambulatory And Capable Of All Selfcare But Unable To Carry Out Any Work Activities. Up And About More Than 50% Of Waking Hours. (2)
CL Item
Capable Of Only Limited Selfcare, Confined To Bed Or Chair More Than 50% Of Waking Hours. (3)
CL Item
Completely Disabled. Cannot Carry On Any Selfcare. Totally Confined To Bed Or Chair. (4)
DataUnknownText
Item
Mark an 'X' if N/A
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C17998 (NCI Thesaurus Property)
C0439673 (UMLS 2011AA Property)
Item Group
History Of Disease
PersonThromboembolismPersonalMedicalHistoryInd-3
Item
Does the patient have a history of thromboembolic events
boolean
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
C0040038 (NCI Metathesaurus Property)
CardiovascularDiseasePresentInd-2
Item
Does the patient have a history of cardiovascular disease
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C25292 (NCI Thesaurus ObjectClass)
C0007226 (UMLS 2011AA ObjectClass)
C2991 (NCI Thesaurus ObjectClass-2)
C0012634 (UMLS 2011AA ObjectClass-2)
CancerInitialDiagnosisDate
Item
Date of Initial Pathologic Diagnosis
date
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
C25509 (NCI Thesaurus Property)
C1279901 (UMLS 2011AA Property)
C15220 (NCI Thesaurus Property-2)
C0011900 (UMLS 2011AA Property-2)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
RecurrentDiseasePriorOnsetMostRecentDate
Item
Date of Most Recent Prior Recurrence
date
C14173 (NCI Thesaurus ObjectClass)
C2945760 (UMLS 2011AA ObjectClass)
C2991 (NCI Thesaurus ObjectClass-2)
C0012634 (UMLS 2011AA ObjectClass-2)
C25629 (NCI Thesaurus Property)
C0332152 (UMLS 2011AA Property)
C25279 (NCI Thesaurus Property-2)
C0332162 (UMLS 2011AA Property-2)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25577 (NCI Thesaurus ValueDomain-2)
C1513491 (UMLS 2011AA ValueDomain-2)
Item Group
Descriptionof Primary Disease
Item
Clinical T Stage
text
C25398 (NCI Thesaurus Property)
C0205210 (UMLS 2011AA Property)
C9385 (NCI Thesaurus ObjectClass)
C0007134 (UMLS 2011AA ObjectClass)
C16899 (NCI Thesaurus ValueDomain)
C1300072 (UMLS 2011AA ValueDomain)
C25728 (NCI Thesaurus Property-2)
C0475455 (UMLS 2011AA Property-2)
CL.5
Code List
Clinical T Stage
CL Item
No Evidence Of Primary Tumor (T0)
CL Item
Tumor 7 Cm Or Less In Greatest Dimension Limited To The Kidney (T1)
CL Item
Tumor Less Than 4 Cm Limited To Kidney (T1a)
CL Item
Tumor Greater Than 4 Cm But Less Than 7 Cm Limited To The Kidney (T1b)
CL Item
Tumor Greater Than 7 Cm In Greatest Dimension Limited To The Kidney (T2)
CL Item
Tumor Extends Into Major Veins Or Invades The Adrenal Gland Or Perinephric Tissues But Not Beyond Gerotas Fascia (T3)
CL Item
Tumor Invades The Adrenal Gland Or Perinephric Tissues But Not Beyond Gerotas Fascia (T3a)
CL Item
Tumor Grossly Extends Into The Renal Vein(s) Or Vena Cava Below The Diaphragm (T3b)
CL Item
Tumor Grossly Extends Into The Renal Vein(s) Or Vena Cava Above The Diaphragm (T3c)
CL Item
Tumor Invades Beyond Gerotas Fascia (T4)
CL Item
Primary Tumor Cannot Be Assessed (TX)
Item
Clinical N Stage
text
C25398 (NCI Thesaurus Property)
C0205210 (UMLS 2011AA Property)
C9385 (NCI Thesaurus ObjectClass)
C0007134 (UMLS 2011AA ObjectClass)
C16899 (NCI Thesaurus ValueDomain)
C1300072 (UMLS 2011AA ValueDomain)
C25580 (NCI Thesaurus Property-2)
C0456532 (UMLS 2011AA Property-2)
CL.6
Code List
Clinical N Stage
CL Item
No Regional Lymph Node Metastasis (N0)
CL Item
Metastasis In A Single Regional Lymph Node (N1)
CL Item
Metastasis In More Than One Regional Lymph Node (N2)
CL Item
Regional Lymph Node Cannot Be Assessed (NX)
Item
Clinical M Stage
text
C25398 (NCI Thesaurus Property)
C0205210 (UMLS 2011AA Property)
C9385 (NCI Thesaurus ObjectClass)
C0007134 (UMLS 2011AA ObjectClass)
C16899 (NCI Thesaurus ValueDomain)
C1300072 (UMLS 2011AA ValueDomain)
C25727 (NCI Thesaurus Property-2)
C0456533 (UMLS 2011AA Property-2)
CL.7
Code List
Clinical M Stage
CL Item
No Distant Metastasis (M0)
CL Item
Distant Metastasis (M1)
C18206 (NCI Thesaurus)
C1269798 (UMLS 2011AA)
CL Item
Distant Metastasis Cannot Be Assessed (MX)
Item Group
Description Of Current Disease
Item
How was disease discovered
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C9385 (NCI Thesaurus ObjectClass)
C0007134 (UMLS 2011AA ObjectClass)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
CL.8
Code List
How was disease discovered
CL Item
Incidental Renal Cell (Incidental renal cell)
CL Item
Symptomatic Renal Cell (Symptomatic renal cell)
Item Group
Current Disease Symptoms
Item
Hematuria (Disease symptoms present prior to surgery)
text
C4876 (NCI Thesaurus ObjectClass)
C1457887 (UMLS 2011AA ObjectClass)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C17173 (NCI Thesaurus Property-2)
C0038894 (UMLS 2011AA Property-2)
C25629 (NCI Thesaurus Property-3)
C0332152 (UMLS 2011AA Property-3)
C3090 (NCI Thesaurus Property-4)
C0018965 (UMLS 2011AA Property-4)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL.9
Code List
Hematuria (Disease symptoms present prior to surgery)
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
Dyspnea (Disease symptoms present prior to surgery)
text
C2998 (NCI Thesaurus ObjectClass)
C0013404 (UMLS 2011AA ObjectClass)
C4876 (NCI Thesaurus ObjectClass-2)
C1457887 (UMLS 2011AA ObjectClass-2)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C17173 (NCI Thesaurus Property-2)
C0038894 (UMLS 2011AA Property-2)
C25629 (NCI Thesaurus Property-3)
C0332152 (UMLS 2011AA Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL.10
Code List
Dyspnea (Disease symptoms present prior to surgery)
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
Pain (Disease symptoms present prior to surgery)
text
C4876 (NCI Thesaurus ObjectClass)
C1457887 (UMLS 2011AA ObjectClass)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C17173 (NCI Thesaurus Property-2)
C0038894 (UMLS 2011AA Property-2)
C3303 (NCI Thesaurus Property-3)
C0030193 (UMLS 2011AA Property-3)
C25629 (NCI Thesaurus Property-4)
C0332152 (UMLS 2011AA Property-4)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL.11
Code List
Pain (Disease symptoms present prior to surgery)
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
Chills (Disease symptoms present prior to surgery)
text
C4876 (NCI Thesaurus ObjectClass)
C1457887 (UMLS 2011AA ObjectClass)
C35143 (NCI Thesaurus ObjectClass-2)
C0085593 (UMLS 2011AA ObjectClass-2)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C17173 (NCI Thesaurus Property-2)
C0038894 (UMLS 2011AA Property-2)
C25629 (NCI Thesaurus Property-3)
C0332152 (UMLS 2011AA Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL.12
Code List
Chills (Disease symptoms present prior to surgery)
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
Fatigue (Disease symptoms present prior to surgery)
text
C3036 (NCI Thesaurus ObjectClass)
C0015672 (UMLS 2011AA ObjectClass)
C4876 (NCI Thesaurus ObjectClass-2)
C1457887 (UMLS 2011AA ObjectClass-2)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C17173 (NCI Thesaurus Property-2)
C0038894 (UMLS 2011AA Property-2)
C25629 (NCI Thesaurus Property-3)
C0332152 (UMLS 2011AA Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL.13
Code List
Fatigue (Disease symptoms present prior to surgery)
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
Fever >38 degrees C or 100 degrees F (Disease symptoms present prior to surgery)
text
C4876 (NCI Thesaurus ObjectClass)
C1457887 (UMLS 2011AA ObjectClass)
C3038 (NCI Thesaurus ObjectClass-2)
C0015967 (UMLS 2011AA ObjectClass-2)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C17173 (NCI Thesaurus Property-2)
C0038894 (UMLS 2011AA Property-2)
C25629 (NCI Thesaurus Property-3)
C0332152 (UMLS 2011AA Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL.14
Code List
Fever >38 degrees C or 100 degrees F (Disease symptoms present prior to surgery)
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
Night sweats (Disease symptoms present prior to surgery)
text
C4876 (NCI Thesaurus ObjectClass)
C1457887 (UMLS 2011AA ObjectClass)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C17173 (NCI Thesaurus Property-2)
C0038894 (UMLS 2011AA Property-2)
C25629 (NCI Thesaurus Property-3)
C0332152 (UMLS 2011AA Property-3)
C3279 (NCI Thesaurus Property-4)
C0028081 (UMLS 2011AA Property-4)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL.15
Code List
Night sweats (Disease symptoms present prior to surgery)
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
Weight loss >= 10% (Disease symptoms present prior to surgery)
text
C4876 (NCI Thesaurus ObjectClass)
C1457887 (UMLS 2011AA ObjectClass)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C17173 (NCI Thesaurus Property-2)
C0038894 (UMLS 2011AA Property-2)
C3445 (NCI Thesaurus Property-3)
C1262477 (UMLS 2011AA Property-3)
C25629 (NCI Thesaurus Property-4)
C0332152 (UMLS 2011AA Property-4)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL.16
Code List
Weight loss >= 10% (Disease symptoms present prior to surgery)
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
Elevated LDH (Disease symptoms present prior to surgery)
text
C4876 (NCI Thesaurus ObjectClass)
C1457887 (UMLS 2011AA ObjectClass)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C17173 (NCI Thesaurus Property-2)
C0038894 (UMLS 2011AA Property-2)
C25629 (NCI Thesaurus Property-3)
C0332152 (UMLS 2011AA Property-3)
C25493 (NCI Thesaurus Property-4)
C0205250 (UMLS 2011AA Property-4)
C25184 (NCI Thesaurus Property-5)
C0022917 (UMLS 2011AA Property-5)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL.17
Code List
Elevated LDH (Disease symptoms present prior to surgery)
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
Low hemoglobin (Disease symptoms present prior to surgery)
text
C4876 (NCI Thesaurus ObjectClass)
C1457887 (UMLS 2011AA ObjectClass)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C25640 (NCI Thesaurus Property-2)
C0392756 (UMLS 2011AA Property-2)
C17173 (NCI Thesaurus Property-3)
C0038894 (UMLS 2011AA Property-3)
C16676 (NCI Thesaurus Property-4)
C0019046 (UMLS 2011AA Property-4)
C25629 (NCI Thesaurus Property-5)
C0332152 (UMLS 2011AA Property-5)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL.18
Code List
Low hemoglobin (Disease symptoms present prior to surgery)
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
Elevated serum calcium (Disease symptoms present prior to surgery)
text
C331 (NCI Thesaurus ObjectClass)
C0006675 (UMLS 2011AA ObjectClass)
C25493 (NCI Thesaurus ObjectClass-2)
C0205250 (UMLS 2011AA ObjectClass-2)
C4876 (NCI Thesaurus ObjectClass-3)
C1457887 (UMLS 2011AA ObjectClass-3)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C17173 (NCI Thesaurus Property-2)
C0038894 (UMLS 2011AA Property-2)
C25629 (NCI Thesaurus Property-3)
C0332152 (UMLS 2011AA Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL.19
Code List
Elevated serum calcium (Disease symptoms present prior to surgery)
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
Other symptoms (Disease symptoms present prior to surgery)
text
C4876 (NCI Thesaurus ObjectClass)
C1457887 (UMLS 2011AA ObjectClass)
C17649 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA Property)
C25626 (NCI Thesaurus Property-2)
C0150312 (UMLS 2011AA Property-2)
C17173 (NCI Thesaurus Property-3)
C0038894 (UMLS 2011AA Property-3)
C25629 (NCI Thesaurus Property-4)
C0332152 (UMLS 2011AA Property-4)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL.20
Code List
Other symptoms (Disease symptoms present prior to surgery)
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
Hematuria (Disease symptoms present after surgery)
text
C4876 (NCI Thesaurus ObjectClass)
C1457887 (UMLS 2011AA ObjectClass)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C17173 (NCI Thesaurus Property-2)
C0038894 (UMLS 2011AA Property-2)
C38008 (NCI Thesaurus Property-3)
C0687676 (UMLS 2011AA Property-3)
C3090 (NCI Thesaurus Property-4)
C0018965 (UMLS 2011AA Property-4)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL.21
Code List
Hematuria (Disease symptoms present after surgery)
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
Dyspnea (Disease symptoms present after surgery)
text
C2998 (NCI Thesaurus ObjectClass)
C0013404 (UMLS 2011AA ObjectClass)
C4876 (NCI Thesaurus ObjectClass-2)
C1457887 (UMLS 2011AA ObjectClass-2)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C17173 (NCI Thesaurus Property-2)
C0038894 (UMLS 2011AA Property-2)
C38008 (NCI Thesaurus Property-3)
C0687676 (UMLS 2011AA Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL.22
Code List
Dyspnea (Disease symptoms present after surgery)
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
Pain (Disease symptoms present after surgery)
text
C4876 (NCI Thesaurus ObjectClass)
C1457887 (UMLS 2011AA ObjectClass)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C17173 (NCI Thesaurus Property-2)
C0038894 (UMLS 2011AA Property-2)
C3303 (NCI Thesaurus Property-3)
C0030193 (UMLS 2011AA Property-3)
C38008 (NCI Thesaurus Property-4)
C0687676 (UMLS 2011AA Property-4)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL.23
Code List
Pain (Disease symptoms present after surgery)
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
Chills (Disease symptoms present after surgery)
text
C4876 (NCI Thesaurus ObjectClass)
C1457887 (UMLS 2011AA ObjectClass)
C35143 (NCI Thesaurus ObjectClass-2)
C0085593 (UMLS 2011AA ObjectClass-2)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C17173 (NCI Thesaurus Property-2)
C0038894 (UMLS 2011AA Property-2)
C38008 (NCI Thesaurus Property-3)
C0687676 (UMLS 2011AA Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL.24
Code List
Chills (Disease symptoms present after surgery)
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
Fatigue (Disease symptoms present after surgery)
text
C3036 (NCI Thesaurus ObjectClass)
C0015672 (UMLS 2011AA ObjectClass)
C4876 (NCI Thesaurus ObjectClass-2)
C1457887 (UMLS 2011AA ObjectClass-2)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C17173 (NCI Thesaurus Property-2)
C0038894 (UMLS 2011AA Property-2)
C38008 (NCI Thesaurus Property-3)
C0687676 (UMLS 2011AA Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL.25
Code List
Fatigue (Disease symptoms present after surgery)
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
Fever >38 degrees C or 100 degrees F (Disease symptoms present after surgery)
text
C4876 (NCI Thesaurus ObjectClass)
C1457887 (UMLS 2011AA ObjectClass)
C3038 (NCI Thesaurus ObjectClass-2)
C0015967 (UMLS 2011AA ObjectClass-2)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C17173 (NCI Thesaurus Property-2)
C0038894 (UMLS 2011AA Property-2)
C38008 (NCI Thesaurus Property-3)
C0687676 (UMLS 2011AA Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL.26
Code List
Fever >38 degrees C or 100 degrees F (Disease symptoms present after surgery)
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
Night sweats (Disease symptoms present after surgery)
text
C4876 (NCI Thesaurus ObjectClass)
C1457887 (UMLS 2011AA ObjectClass)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C17173 (NCI Thesaurus Property-2)
C0038894 (UMLS 2011AA Property-2)
C38008 (NCI Thesaurus Property-3)
C0687676 (UMLS 2011AA Property-3)
C3279 (NCI Thesaurus Property-4)
C0028081 (UMLS 2011AA Property-4)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL.27
Code List
Night sweats (Disease symptoms present after surgery)
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
Weight loss >= 10% (Disease symptoms present after surgery)
text
C4876 (NCI Thesaurus ObjectClass)
C1457887 (UMLS 2011AA ObjectClass)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C17173 (NCI Thesaurus Property-2)
C0038894 (UMLS 2011AA Property-2)
C3445 (NCI Thesaurus Property-3)
C1262477 (UMLS 2011AA Property-3)
C38008 (NCI Thesaurus Property-4)
C0687676 (UMLS 2011AA Property-4)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL.28
Code List
Weight loss >= 10% (Disease symptoms present after surgery)
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
Elevated LDH (Disease symptoms present after surgery)
text
C4876 (NCI Thesaurus ObjectClass)
C1457887 (UMLS 2011AA ObjectClass)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C17173 (NCI Thesaurus Property-2)
C0038894 (UMLS 2011AA Property-2)
C38008 (NCI Thesaurus Property-3)
C0687676 (UMLS 2011AA Property-3)
C25493 (NCI Thesaurus Property-4)
C0205250 (UMLS 2011AA Property-4)
C25184 (NCI Thesaurus Property-5)
C0022917 (UMLS 2011AA Property-5)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL.29
Code List
Elevated LDH (Disease symptoms present after surgery)
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
Low hemoglobin (Disease symptoms present after surgery)
text
C16676 (NCI Thesaurus ObjectClass)
C0019046 (UMLS 2011AA ObjectClass)
C4876 (NCI Thesaurus ObjectClass-2)
C1457887 (UMLS 2011AA ObjectClass-2)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C17173 (NCI Thesaurus Property-2)
C0038894 (UMLS 2011AA Property-2)
C38008 (NCI Thesaurus Property-3)
C0687676 (UMLS 2011AA Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL.30
Code List
Low hemoglobin (Disease symptoms present after surgery)
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
Elevated serum calcium (Disease symptoms present after surgery)
text
C331 (NCI Thesaurus ObjectClass)
C0006675 (UMLS 2011AA ObjectClass)
C25493 (NCI Thesaurus ObjectClass-2)
C0205250 (UMLS 2011AA ObjectClass-2)
C4876 (NCI Thesaurus ObjectClass-3)
C1457887 (UMLS 2011AA ObjectClass-3)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C17173 (NCI Thesaurus Property-2)
C0038894 (UMLS 2011AA Property-2)
C38008 (NCI Thesaurus Property-3)
C0687676 (UMLS 2011AA Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL.31
Code List
Elevated serum calcium (Disease symptoms present after surgery)
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
Other symptoms (Disease symptoms present after surgery)
text
C4876 (NCI Thesaurus ObjectClass)
C1457887 (UMLS 2011AA ObjectClass)
C17649 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA Property)
C25626 (NCI Thesaurus Property-2)
C0150312 (UMLS 2011AA Property-2)
C17173 (NCI Thesaurus Property-3)
C0038894 (UMLS 2011AA Property-3)
C38008 (NCI Thesaurus Property-4)
C0687676 (UMLS 2011AA Property-4)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
CL.32
Code List
Other symptoms (Disease symptoms present after surgery)
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)
SymptomPriorSurgeryOtherPresentSpecify
Item
Specify other symptoms (Disease symptoms present after surgery)
text
C4876 (NCI Thesaurus ObjectClass)
C1457887 (UMLS 2011AA ObjectClass)
C17649 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA Property)
C25626 (NCI Thesaurus Property-2)
C0150312 (UMLS 2011AA Property-2)
C17173 (NCI Thesaurus Property-3)
C0038894 (UMLS 2011AA Property-3)
C25629 (NCI Thesaurus Property-4)
C0332152 (UMLS 2011AA Property-4)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item Group
Muga Scanning
HeartMUGATestDate
Item
Date of assessment
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C12727 (NCI Thesaurus ObjectClass)
C0018787 (UMLS 2011AA ObjectClass)
C38073 (NCI Thesaurus Property)
C0521317 (UMLS 2011AA Property)
C25294 (NCI Thesaurus Property-2)
C0022885 (UMLS 2011AA Property-2)
HeartLVEFTestPercentageValue
Item
Left Ventricular Ejection Fraction at Rest
float
C12727 (NCI Thesaurus ObjectClass)
C0018787 (UMLS 2011AA ObjectClass)
C25294 (NCI Thesaurus Property)
C0022885 (UMLS 2011AA Property)
C37946 (NCI Thesaurus Property-2)
C2700377 (UMLS 2011AA Property-2)
C25613 (NCI Thesaurus ValueDomain)
C0439165 (UMLS 2011AA ValueDomain)
C25712 (NCI Thesaurus ValueDomain-2)
C1522609 (UMLS 2011AA ValueDomain-2)
HeartLVEFTestPercentageLowerLimitofNormalValue
Item
LVEF Institutional Lower Limit of Normal
float
C12727 (NCI Thesaurus ObjectClass)
C0018787 (UMLS 2011AA ObjectClass)
C25294 (NCI Thesaurus Property)
C0022885 (UMLS 2011AA Property)
C37946 (NCI Thesaurus Property-2)
C2700377 (UMLS 2011AA Property-2)
C25613 (NCI Thesaurus ValueDomain)
C0439165 (UMLS 2011AA ValueDomain)
C25712 (NCI Thesaurus ValueDomain-2)
C1522609 (UMLS 2011AA ValueDomain-2)
C25555 (NCI Thesaurus ValueDomain-3)
C1518030 (UMLS 2011AA ValueDomain-3)
EchocardiogramDate
Item
Date of assessment (Note: If patient was unable to obtain MUGA scan due to the shortage of the isotope Technetium-99, an ECHO may be substituted - at baseline and all subsequent visits for new patients. In this case, fill in the section below.)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C37945 (NCI Thesaurus ObjectClass)
C2243117 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
Item Group
Footer Module
Investigator Signature
Item
Investigator Signature
text
C25704 (NCI Thesaurus ValueDomain)
C2346576 (UMLS CUI-1)
C25678 (NCI Thesaurus Property)
C17089 (NCI Thesaurus ObjectClass)
Investigator Signature Date
Item
Investigator Signature Date
date
C25164 (NCI Thesaurus ValueDomain)
C2346576 (UMLS CUI-1)
C25678 (NCI Thesaurus Property)
C0011008 (UMLS CUI-2)
C25367 (NCI Thesaurus ValueDomain-2)
C17089 (NCI Thesaurus ObjectClass)
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