Institution INSTRUCTIONS (M3) - All other imaging studies, including CT, CONVENTIONAL MRI, PET SCINTIGRAPHY, etc... AND
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1 M3 ACRIN 6660 Whole Body MRI in the Evaluation of Pediatric Malignancies Whole Body MRI Imaging Form No. Revised/corrected form, check box and fax to INSTRUCTIONS (M3) 1. This form is to be completed by a DESIGNATED STUDY PEDIATRIC RADIOLOGIST 2. It is crucial that interpretation of the WHOLE BODY MRI study be done BLIND to: - All other imaging studies, including CT, CONVENTIONAL MRI, PET SCINTIGRAPHY, etc... - Surgical and pathologic information/reports. AND 3. For WHOLE BODY MRI interpretations, please note that STIR images must be interpreted first, without knowledge of OOPS imaging. This is PART II of the form. PART III of the form is for intrepretation based on the combination of STIR and OOPS imaging. 4. If the WHOLE BODY MRI was not done, put the scheduled date of the MRI in Question 1, answer Question 2 and 2a, then skip to the end of the form. 5. For image quality, a response of 3 Inadequate is based on imaging defined as not evaluable M3b of 10
2 M3 ACRIN 6660 Whole Body MRI in the Evaluation of Pediatric Malignancies Whole Body MRI Imaging Form No. Revised/corrected form, check box and fax to INSTRUCTIONS: To be completed by study designated Radiologist. Submit via ACRIN Website. Interpretations to be done blind to PET, Conventional MRI and Surgical/Pathological reports. Part I Whole Body MRI 1. Date of Whole Body MRI exam: - - (mm-dd-yyyy) 2. Was Whole Body MRI exam completed? 1 No* (complete Question 2a, then skip to end of form) 2 Yes 2a. *If no, give reason: o Scheduling problem o Equipment failure o Patient unable to cooperate o Clinically unstable o Sedation failure o Patient motion o Other, specify: o Unknown 3. Date of Whole Body MRI interpretation: - - (mm-dd-yyyy) 4. Name of Reader: 5. Reader ID: 6. : Whole Body MRI Start time 7. : Whole Body MRI End time Record start and end sequence times for FAST MRI only (Do not include time spent positioning patient or setting up the MRI room, etc.) Utilize a 24 hour format. 8. Was patient sedated? o No o Yes 6660 M3b of 10
3 Part II Interpretation of Whole Body (Turbo) STIR (FSE-XLIR) only 1. Was Whole Body (Turbo) STIR (FSE-XLIR) completed? o No o Yes 2. Rate the image quality of the Whole Body (Turbo) STIR (FSE-XL IR) sequences: o Adequate o Suboptimal o Inadequate (skip to Part III) No. 3. Indicate Bone Metastases seen with Whole Body (Turbo) STIR (FSE-XL IR) Skull C-Spine Humerus (right) Humerus (left) Radius/ulna (right) Radius/ulna (left) Hand (right) Hand (left) Ribs (right) Ribs (left) Scapula/Clavicle Sternum T-spine 6660 M3b of 10
4 No. 3. Bone Metastases continued... L-spine Femur (right) Femur (left) Tibia/fibula (right) Tibia/fibula (left) Foot (right) Foot (left) Other, specify: 4. Indicate any Lymphadenopathy seen with Whole Body (Turbo) STIR (FSE-XL IR) Cervical Hilar Upper extremity (right) Upper extremity (left) Supraclavicular Chest, axillary Chest, mediastinal Abdomen Lower extremity (right) Lower extremity (left) Other, specify 6660 M3b of 10
5 M3 Revision No. 5. Additional Non-Skeletal findings seen with Whole Body (Turbo) STIR (FSE-XL IR) 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 Soft tissue, lower extremity (right) Soft tissue, lower extremity (left) Other, specify: 6660 M3b of 10
6 6. What is your overall confidence in the Stage IV as seen with Whole Body (Turbo) STIR (FSE-XL IR)? 5 Definitely present No. 7. % What is your estimated probability of the Stage IV as seen with Whole Body (Turbo) STIR (FSE-XL IR)? (100%=highest) 8. Comments regarding Whole Body (Turbo) STIR (FSE-XL IR): Continue to next page, Part III 6660 M3b of 10
7 Part III Combined STIR and OOPS Imaging 1. Was OOPS Imaging completed? o No o Yes 2. Rate the image quality of the OOPS sequences o Adequate o Suboptimal o Inadequate (skip to end of form) 3. Indicate Bone Metastases seen with STIR plus OOPS No. Skull C-Spine Humerus (right) Humerus (left) Radius/ulna (right) Radius/ulna (left) Hand (right) Hand (left) Ribs (right) Ribs (left) Scapula/Clavicle Sternum T-spine 6660 M3b of 10
8 3. Bone Metastases continued... No. L-spine Femur (right) Femur (left) Tibia/fibula (right) Tibia/fibula (left) Foot (right) Foot (left) Other, specify: 4. Indicate any Lymphadenopathy seen with STIR and OOPS Cervical Hilar Upper extremity (right) Upper extremity (left) Supraclavicular Chest, axillary Chest, mediastinal Abdomen Lower extremity (right) Lower extremity (left) Other, specify 6660 M3b of 10
9 M3 Revision No. 5. Additional Non-Skeletal findings seen with STIR and OOPS. 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 Soft tissue, lower extremity (right) Soft tissue, lower extremity (left) Other, specify: 6660 M3b of 10
10 No. 6. What is your overall confidence in the Stage IV as seen with STIR and OOPS? 5 Definitely present 7. % What is your estimated probability of the Stage IV as seen with STIR and OOPS? (100%=highest) 8. Comments regarding STIR and OOPS: OVERALL COMMENTS: - - Signature of person responsible for data 1 Date form completed Signature of person entering data into web M3b of 10
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