Gastric Cancer and CNS involvement registry - Spreadsheet V 1
CRITERIA DATAENTRY INFO
INITIALS FIRST NAME - LAST NAME
DOB DATE OF BIRTH
CENTER
UPN NUMBER given by trial coordinator
AGE AT DIAGNOSIS
GENDER
ETHNICITY
PERFORMANCE STATUS
ANTIEPILEPTIC DRUGS
THROMBOSIS Intracranial
Extracranial
ANTICOAGULATION Yes No
PRIMARY TUMOR - LOC LOCALISATION
PRIMARY TUMOR - N NODAL INVOLVEMENT (Ultrasound, CT, PET-CT)
GRADE
HISTOLOGY
LAUREN CLASSIFICATION
SIGNET CELLS
HER-2 (PRIMARY) IHC score
HER-2 (MET) IHC score
MET SITE NUMBER METASTATIC SITES outside CNS at time of Dx BRAIN MET
LIVER MET
PERITONEAL MET
HB Hemoglobin
DATE DIAG TIME OF DIAGNOSIS OF BRAIN METS
DX BRAIN MET FALSE MODE
SEQUENCE BRAIN MET vs PRIMARY TUMOR
LIQUOR AT TIME OF DIAGNOSIS
HER-2 (LIQU) IHC SCORE
HER-2 (BRAIN MET) IHC SCORE
GASTRECTOMY
NEO / ADJUVANT Cx
INTRATHECAL Cx if possible document chemotherapy (eg medical record)
RADIOTHERAPY If possible document radiotherapy (eg medical record)
PROTOCOL
PROTOCOL NAME ADD PROTOCOL NAME
SYSTEMIC Cx NUMBER CHEMOTHERAPY LINES (after diagnosis of brain mets)
If possible document chemotherapy (eg medical record)
SURVIVAL
SURVIVAL DATE DATE OF LAST CONTACT OR DATE OF DEATH
CD-ROM BRAIN IMAGING (CT-Scan, MRI)
STAINED SLIDES PRIMARY TUMOR, METS, BRAIN METS
UNSTAINED SLIDES PRIMARY TUMOR, METS, BRAIN METS
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