ACRIN NLST 6654 Primary Lung Cancer. F1/F2 Interval: to (mm-dd-yyyy) 1. Date of diagnosis: (mm-dd-yyyy)

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1 No. F1/F2 Interval: to (mm-dd-yyyy) 1. Date of diagnosis: (mm-dd-yyyy) 2. Samples recorded: ZP Number S-Number 1) 2) 3) 4) (Refer to Form PX, Column 1. In the rare instance of a diagnosis of lung cancer in the absence of any pathologic specimen, record 98 = Not Applicable) 2a. c. Topography Morphology Behavior Grade 2b. Source of samples for ICD-0-3 code: 1 = Cytology 2 = Histology 3 = Combined 2c. Is this a synchronous primary cancer? 1 = No 2 = Yes 2d. If a synchronous primary, please designate this as Cancer A, B, or C 6654 ZL of 6

2 No. 3. Chart Anatomic Location (s) of Maximum Diameter Primary Lesion Basis of Lesion Size Sites of Metastases How Metastases Confirmed? 1 = RUL 2 = RML 3 = RLL 4 = LUL 5 = Lingula 6 = LLL 7 = R Hilum 8 = L Hilum 9 = RMSB 10 = LMSB 11 = Carina 12 = Mediastinum 13 = Other, specify 99 = Unknown mm 999 = Not available 1 = Clinical 2 = Pathology 99 = No Size 0 = No metastases 1 = Brain 2 = Pleura 3 = Lung, not primary site 4 = Liver 5 = Adrenal 6 = Bone 7 = Other, specify 99 = Unknown 0 = None 1 = Clinical 2 = Pathology 3 = Cytology 99 = Unknown 6654 ZL of 6

3 No. 4a. Is there evidence of nodal involvement by primary lung cancer? 1 No (skip to Q6. Nodal status for staging purposes = N0) 2 Yes (Complete Q4b and Q4c) 99 Not available (skip to Q6. Nodal status for staging purposes = NX) 4b. Was nodal involvement documented by clinical means? The following responses apply: 1 No = There is no documentation of clinical nodal involvement. (Do not complete Q5 Tables 5A or 5B: Clinical Diagnosis) 2 Yes = There is documentation of clinical nodal involvement by ATS nodal mapping. (Complete Table 5A: Clinical Diagnosis) 3 Yes = There is documentation of clinical nodal involvement by TNM description only. (Complete Table 5B: Clinical Diagnosis) 4c. Was nodal involvement documented by pathologic means? The following responses apply: 1 No = There is no documentation of pathologic nodal involvement. (Do not complete Q5 Tables 5A or 5B: Pathologic Diagnosis) 2 Yes = There is documentation of pathologic nodal involvement by ATS nodal mapping. (Complete Table 5A: Pathologic Diagnosis) 3 Yes = There is documentation of pathologic nodal involvement by TNM description only. (Complete Table 5B: Pathologic Diagnosis) 6654 ZL of 6

4 No. 5. For each lymph node station, record the presence or absence of involvement by lung cancer based upon both clinical and pathological methods of determination separately. If there is no data to base a determination for a given lymph region, record "99" No data available (# nodes) and "0" (Mode of diagnosis). Complete the tables according to responses provided in Q4B (clinical means) and Q4C (pathological means). Table 5A Lymph Node Chain 1 Supraclavicular 2R Right upper paratracheal 2L Left upper paratracheal 3 Prevascular and Retrotracheal 4R Right lower paratracheal 4L Left lower paratracheal 5 AP window/subaortic 6 Para-aortic, ascending aorta or phrenic 7 Subcarinal 8 Paraesophageal 9 Pulmonary Ligament 10R Right hilar 10L Left hilar 11R Right interlobar 11L Left interlobar 12R Right lobar 12L Left lobar 13R Right segmental 13L Left segmental 14R Right subsegmental 14L Left subsegmental Clinical Diagnosis Pathologic Diagnosis # Nodes Mode of Diagnosis # Nodes 0 = 0 nodes involved 0 = No clinical information 0 = 0 nodes involved 1 = CXR 4 = PET/CT 2 = CT 5 = MRI 3 = PET 6 = Other, specify Insert codes in for Other, specify 99 = No data available the columns below; fill in here 99 = No data available 6654 ZL of 6

5 No. Complete Table B for clinical or pathologic staging only if medical records indicate nodal involvement without reference to specific regions. Table 5B Lymph Node Chain N1 = Ipsilateral hilar or more distal nodes N2 = Ipsilateral mediastinal nodes N3 = Contralateral hilar, mediastinal, or scalene nodes Clinical Diagnosis Pathologic Diagnosis # Nodes Mode of Diagnosis # Nodes 0 = 0 nodes involved 0 = No clinical information 0 = 0 nodes involved 1 = CXR 4 = PET/CT 2 = CT 5 = MRI 3 = PET 6 = Other, specify Insert codes in for Other, specify 99 = No data available the columns below; fill in here 99 = No data available Record the staging for primary lung cancer. 6. TNM Clinical Stage: 7. TNM Pathologic Stage: T Codes N Codes M Codes T Codes N Codes M Codes TX NX MX TX NX MX T0 N0 M0 T1 N0 M0 T1 N1 M1 T2 N1 M1 T2 N2 T3 N2 T3 N3 T4 N3 T ZL of 6

6 No. 8. Record Stage: Enter the stage of primary lung cancer based upon the data elements. Stage Only (Non-Small Cell and Small Cell Histology) VALCSG (Small Cell only) Summary Staging Occult IIA IIIB IA IIB IV IB IIIA Limited Extensive Localized Regional Distant Post-Neo-adjuvant therapy? No Yes Describe Treatment: 9. Was another primary lung cancer diagnosed during this same interval? No Yes (complete an additional ZL Form for each individual primary lung cancer diagnosed during this time interval) 10. Were the medical records required for the ZL Form for this F1/F2 Interval complete? No (complete an additional records request) Yes 11. This form was created in error and should be deleted and all information should be ignored = marked, = not marked 11a. Reason for form deletion: (choose only one) 01 Query response 02 Data entry error correction 03 Audit QC Finding correction 04 Site revision 12. Comments: CTR Coder ID: CTR Coder Signature: Date Form Completed: (mm-dd-yyyy) 6654 ZL of 6