BX
ACRIN 6660
ACRIN Study 6660
Whole Body MRI in the Evaluation of
Pediatric Malignancies
Biopsy Form
Case #
PLACE LABEL HERE
Institution
Institution No.
Participant's Initials
Participant's I.D. No.
If this is a revised or corrected form, indicate by checking box.
INSTRUCTIONS: Complete a form for all biopsies, use separate form(s) for each procedure.
via the ACRIN website www.acrin.org.
1.
Procedure date
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-
(mm-dd-yyyy)
2.
Number of biopsy procedures (If more than one procedure, complete another BX form)
3.
Biopsy number (reported on this form)
4.
Type of procedure
1
2
3
4
8
99
5.
FNA
Core needle biopsy
FNA and core needle biopsy
Surgical (wedge, excisional, etc . . .) biopsy
Other, specify
Unknown
Image guided
1
2
8
99
6.
S u b m i t f o r m( s )
No
Yes
Other, specify
Unknown
Location of biopsy
1
2
3
4
5
6
8
Lung (complete Q6a and continue)
Liver (complete Q6b and continue)
Soft Tissue (complete Q6c and continue)
Bone / bone marrow (complete Q6d and continue)
Brain (complete - "Other, specify field" in Q6d and continue)
Lymph node distant from primary site (complete Q6e and continue)
Other, specify
Anatomic Locations
6a.
Lung
1
2
3
4
5
6b.
Liver
1
2
3
4
5
"Copyright 2005"
RUL
RML
RLL
LUL
LLL
Right lobe, anterior
Right lobe, posterior
Left lobe, medial
Left lobe, lateral
Caudate
ACRIN 6660 BXb
09-20-05
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BX
6c.
Institution No.
Participant's Initials
Participant's I.D. No.
Head and Neck
Upper extremity,
Upper extremity,
Chest wall
Abdominal wall
Pelvis
Lower extremity,
Lower extremity,
right
left
right
left
Bone / bone marrow
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
L-spine
Pelvis
Femur, right
Femur, left
Tibia / fibula, right
Tibia / fibula, left
Foot, right
Foot, left
Other, specify
Lymph node distant from primary site
1
2
3
4
5
6
7
8
9
10
11
18
"Copyright 2005"
Institution
Soft Tissue
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
28
6e.
Case #
PLACE LABEL HERE
1
2
3
4
5
6
7
8
6d.
ACRIN Study 6660
Revision
Cervical
Hilar
Upper extremity, right
Upper extremity, left
Supraclavicular
Chest, axillary
Chest, mediastinal
Abdomen
Pelvis
Lower extremity, right
Lower extremity, left
Other, specify
ACRIN 6660 BXb
09-20-05 2 of 3
BX
7.
ACRIN Study 6660
Revision
Case #
PLACE LABEL HERE
Institution
Institution No.
Participant's Initials
Participant's I.D. No.
Histology
1
2
3
4
8
9
Negative
Positive (for stage IV disease)
Indeterminate
Specimen inadequate
Other, specify
Positive
COMMENTS:
Date from completed
Signature of person responsible for the data
Signature of person entering data onto the web
"Copyright 2005"
-
-
(mm-dd-yyyy)
1
2
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