Medal Study No.
MEDAL STUDY
MRI REPORT (Form 7a and 7b) (NOT TO BE STORED ON CRS/ RIS)
Patient Initials
Office note: This form to be used with Form 10 MRI Report Inde Review V0.7 – 4th March 2013
Scan performed by: ................................... Position ............................... MRI Report Completed by: ....................... Position......................... MRI scanner make/model ................../................
MRI scan date: D
M
D
M
Y
M
Y
Y
Y
MRI scan start time: H
H :M M
MRI scan end time: H
H
:M M
Note:
MRI Scan start time = time first image obtained
Part A Sequences performed
MRI Scan end time = time final image obtained
T1
Plane
Axial
Performed?
Subjective assessment
of quality
No
Slice
thickness
(mm)
Yes
Good
Satisfactory
Inadequate
Poor
Sagittal
Coronal
Additional
sequences
No
T2
Inter
slice
gap
(%)
MRI Report Form
FOV
Performed?
Subjective assessment
of quality
No
Slice
thickness
(mm)
Yes
No
Inter
slice
gap
(%)
FOV
Performed?
Subjective assessment
of quality
No
Good
Satisfactory
Inadequate
Poor
Yes
T1-FS
Yes
No
No
No
No
Good
Satisfactory
Inadequate
Poor
Good
Satisfactory
Inadequate
Poor
No
No
No
Good
Satisfactory
Inadequate
Poor
Good
Satisfactory
Inadequate
Poor
Yes
No
Yes
Yes
Good
Satisfactory
Inadequate
Poor
Yes
No
Yes
Yes
No
Good
Satisfactory
Inadequate
Poor
Yes
These reading can be collected from scan legend at a later stage.
MRI Report (Form 7a and 7b)
Page 1 of 5
Contrast
Yes
Good
Satisfactory
Inadequate
Poor
Yes
FOV
No
Good
Satisfactory
Inadequate
Poor
Good
Satisfactory
Inadequate
Poor
Yes
Inter
slice
gap
(%)
Yes
Good
Satisfactory
Inadequate
Poor
Yes
Slice
thickness
(mm)
Version 1.7 – 4th March 2013
Part B Uterus
1. Size (to include cervix) Length ……………….. cm Thickness ……………… cm Transverse …………………. cm
2. Appearance : Normal
Abnormal
3. Fibroids present? No
Yes
If abnormal, describe .......................................................................................................................................
If yes, Number …………..
Dimensions of largest
4. Endometrial thickness
Length
Thickness
Transverse
…………..………… cm
…………..…….….. cm
.……………………. cm
....................................................mm
5. Junctional zone thickness
Anterior wall ................. mm
Fundus ................ mm
Posterior wall
..............mm
6. Myometrium adjacent to JZ measurement
Anterior wall ................. mm
Fundus ................ mm
Posterior wall
..............mm
(Full myometrial thickness to include JZ)
Part C Ovaries
Ovary
LEFT
Present
No
Yes
RIGHT
No
Yes
Location
Length (cm)
Width (cm)
Transverse
(cm)
Volume
(ml)
Abutting Uterus
 Posteriorly
 Anteriorly
 Posterior-laterally
No
Yes
If yes, size of
largest
Pelvic side wall
Other (describe)
....................................
Abutting Uterus
 Posteriorly
 Anteriorly
 Posterior-laterally
T1
Signal Intensity
T2
T1-FS
High
High
High
Intermediate
Intermediate
Intermediate
Low
Low
Low
High
High
High
Intermediate
Intermediate
Intermediate
Low
Low
Low
………… mm
No
Yes
If yes, size of
largest
Pelvic side wall
Other (describe)
....................................
MRI Report (Form 7a and 7b)
Cysts
present
(other than
follicles)
......……. mm
Page 2 of 5
Version 1.7 – 4th March 2013
Part D Other observations
Site
Mass observed
TUBAL
No
Location of origin relative to
uterus
Medial
Yes
PARA-OVARIAN
BOWEL
Number of
masses
Size of largest
Length
………….. cm
Lateral
Width
………….. cm
Right
Other (describe)
Transverse ..………… cm
Left
....................................
No
Medial
Length
………….. cm
Yes
Lateral
Width
………….. cm
Right
Other (describe)
Transverse ..………… cm
Left
....................................
No
Small
Length
………….. cm
Yes
Sigmoid
Width
………….. cm
Rectum
Transverse ..………… cm
Other (describe)
Signal Intensity
T1
T2
T1-FS
High
High
High
Intermediate
Intermediate
Intermediate
Low
Low
Low
High
High
High
Intermediate
Intermediate
Intermediate
Low
Low
Low
High
High
High
Intermediate
Intermediate
Intermediate
Low
Low
Low
....................................
Presence of (abnormal) small bowel in pelvis
Normal
Bowel thickening?
No
Abnormal
Yes
If abnormal, enhanced with contrast
No
Sigmoid/ rectum
No
Yes
Mesenteric/ antimesenteric
No
Yes
Mucosal/ submucosal
No
Yes
Yes
BLADDER
Dome
Length
………….. cm
No
Posterior
Width
………….. cm
Yes
Anterior
Transverse .………… cm
Other (describe)
High
High
High
Intermediate
Intermediate
Intermediate
Low
Low
Low
....................................
MRI Report (Form 7a and 7b)
Page 3 of 5
Version 1.7 – 4th March 2013
If abnormal, bladder wall thickness
Normal
Trigone [perpendicular to Lumen at thickest part of Trigone] ...…….. mm
Abnormal
Bladder volume ................ ml
Dome, Midline ………….….......... mm
Anterior wall, midline ……........ mm
4
OTHER
(Please specify)
No
Other (describe)
Length
………….. cm
Yes
....................................
Width
………….. cm
....................................
Transverse ..………… cm
High
High
High
Intermediate
Intermediate
Intermediate
Low
Low
Low
Part E: Other observations
Fluid observed
4
No
Physiological
Yes
Adhesions
No
Clearly seen
Suspected
Free fluid
Loculated fluid
No
No
Yes
Yes
Clearly seen? Organs implicated
Suspected? Reason
1. ......................................................................
Distortion of margins
No
Yes
2. ......................................................................
Proximity of organs
No
Yes
3. ......................................................................
Other (specify)
No
Yes
Please forward completed form and
anonymised MRI Scans (one CD per
patient) via a courier service to:
Mr Lee Priest
MEDAL Study
Birmingham Clinical Trials Unit
School of Cancer Sciences
Robert Aitken Institute
University of Birmingham
Birmingham B15 2TT
Further Notes
MRI Report (Form 7a and 7b)
Page 4 of 5
Version 1.7 – 4th March 2013
Medal Study No.
Part F Summary Diagnosis - Form 7(b) MRI Synopsis
Patient Initials
Please forward completed form and anonymised MRI Scans (one CD per patient) via a courier
service to:
Mr Lee Priest
MEDAL Study
Birmingham Clinical Trials Unit
School of Cancer Sciences
Robert Aitken Institute
University of Birmingham
Birmingham B15 2TT
MRI Report (Form 7a and 7b)
Page 5 of 5
Fax: 0121 415 9136 (please notify BCTU upon faxing document -thTel - 0121 414 6665)
Version 1.7 – 4 March 2013