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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