Institution INSTRUCTIONS (I6) 1. This form is to be completed by a DESIGNATED STUDY NUCLEAR MEDICINE SPECIALIST

Transcription

1 I6 ACRIN 6660 Whole Body MRI in the Evaluation of Pediatric Malignancies Conventional Scintigraphy Imaging Form If this is a revised or corrected form, indicate by checking box and fax to INSTRUCTIONS (I6) 1. This form is to be completed by a DESIGNATED STUDY NUCLEAR MEDICINE SPECIALIST 2. It is crucial that interpretation of the SCINTIGRAPHY study be done BLIND to: - All other imaging studies, including CT, CONVENTIONAL AND WHOLE BODY MRI, SCINTIGRAPHY, etc... - Surgical and pathologic information/reports. AND 3. If the SCINTIGRAPHY Scan was not completed, put the scheduled date of the scan in Question 1, answer Question 2 and 2a, then skip to the end of the form. "copyright 2005" 6660 I6b of 6

2 I6 ACRIN 6660 Whole Body MRI in the Evaluation of Pediatric Malignancies Conventional Scintigraphy Imaging Form Revised/corrected form, check box and fax to INSTRUCTIONS: Complete and submit a separate form for each type of Scintigraphy obtained for a given case. Submit this form via the ACRIN website. 1. Date of Scintigraphy examination - - (mm-dd-yyyy) If the SCINTIGRAPHY Scan was not completed, put the scheduled date of the scan in Question 1, answer Question 2 and 2a, then skip to the end of the form. 2. Was Scintigraphy exam completed? 1 No* 2 Yes *2a. If no, give reason: 1 Scheduling problem 2 Equipment failure 3 Patient unable to cooperate 4 Clinically unstable 5 Sedation failure 6 Patient motion 8 Other, specify: 99 Unknown 3. Date of Scintigraphy interpretation: - - (mm-dd-yyyy) 4. Name of Scintigraphy Reader: 6. Which type of Scintigraphy was performed? 1 Bone (99m Tc - MDP) [Complete All questions except Q14] 2 67 Ga 3 I23 I - MIBG I - MIBG 1 7. Image quality for diagnosis: 1 Adequate 2 Suboptimal 3 Inadequate (skip to end) 8. Patient's weight kg 9. Isotope dose administered mci 10. Elapsed time between injection and initial scan hrs 10a. Delayed imaging time(s) if applicable (between injection and scan) hrs 11. Type Imaging 1 Planar 2 SPECT 3 Planar and SPECT hrs hrs 5. Reader ID: 12. Patient Sedated 1 No 2 Yes "copyright 2005" 6660 I6b of 6

3 13. Indicate Bone Metastases seen with Scintigraphy Skull C-Spine presence of disease Humerus (right) Humerus (left) Radius/ulna (right) Radius/ulna (left) Hand (right) Hand (left) Ribs (right) Ribs (left) Scapula/Clavicle Sternum T-spine "copyright 2005" 6660 I6b of 6

4 13. Bone Metastases continued... L-spine Pelvis presence of disease Femur (right) Femur (left) Tibia/fibula (right) Tibia/fibula (left) Foot (right) Foot (left) Other, specify: 14. Indicate any Lymphadenopathy seen with Scintigraphy Cervical Hilar Upper extremity (right) Upper extremity (left) Supraclavicular Chest, axillary Chest, mediastinal Abdomen Pelvis Lower extremity (right) Lower extremity (left) Other, specify presence of disease "copyright 2005" 6660 I6b of 6

5 15. Additional Non-Skeletal findings seen with Scintigraphy Brain Head/Neck Soft Tissue, upper extremity (right) Soft Tissue, upper extremity (left) Lungs (right) Lungs (left) Pleura Chest Wall Liver Spleen Pancreas Adrenal gland (right) Adrenal gland (left) Kidney (right) Kidney (left) Bowel/Mesentery/Peritoneum Abdominal Wall Pelvis Soft tissue, lower extremity (right) Soft tissue, lower extremity (left) Other, specify: presence of disease "copyright 2005" 6660 I6b of 6

6 16. What is your overall confidence in the presence of Stage IV disease? 5 Definitely present 17. % What is your estimated probability of the presence of Stage IV disease? (100=highest) OVERALL COMMENTS: Signature of person responsible for data Date form completed (mm-dd-yyyy) Signature of person entering data into web 2 "copyright 2005" 6660 I6b of 6