Form 27 Post Transplant Malignancy

Records
Adult Post-Transplant Malignancy Worksheet
The revised worksheet sample is for reference purposes only and is pending OMB approval.
Note: These worksheets are provided to function as a guide to what data will be required in the online TIEDI

B.

application. Currently in the worksheet, a
B.

red asterisk is displayed by fields that are required, independent of what other data may be provided. Based on data provided through the online TIEDI
application, additional fields that are dependent on responses provided in these required fields may become required as well. However, since those fields
are not required in every case, they are not marked with a red asterisk.

RECIPIENT INFORMATION
Recipient name:

Date of birth:

Recipient SSN:

Recipient organ:

TRF:

Follow-up code:

Transplant date:
Follow-up center::
Recipient Center:

DONOR RELATED
Tumors transmitted from the donor
Diagnosis date:

j Immunosuppression Stopped
k
l
m
n
Immunosuppression:

j Immunosuppression Reduced
k
l
m
n
j No Immunosuppression Adjustment
k
l
m
n

Tumor type:

j Primary to the transplanted organ
k
l
m
n
j Not primary to the transplanted organ
k
l
m
n

Specify treatment:

c Surgical resection tumor
d
e
f
g
c Chemotherapy:
d
e
f
g
Other specify:

c Radiation
d
e
f
g
j Hormonal Therapy
k
l
m
n
j Interferon Alpha
k
l
m
n
c Immunotherapy:
d
e
f
g

j Prednisone
k
l
m
n
j Rituximab
k
l
m
n
j Other, specify
k
l
m
n

Other specify:
Other treatment specify:

j Alive, Free of Tumor
k
l
m
n

j Alive with Tumor
k
l
m
n
Outcome:

j Dead, due to tumor
k
l
m
n
j Dead, other causes
k
l
m
n

RECURRENCE OF PRETRANSPLANT MALIGNANCY
Type of pre-existing tumor:
If skin # of occurrences in follow-up period:

j A
k
l
m
n
If Color-rectal, Duke's Classificiation:

j B
k
l
m
n
j C
k
l
m
n
j Unknown
k
l
m
n

If Lymphoma specify type:

j AML
k
l
m
n
j ALL
k
l
m
n
If Leukemia:

j MDS
k
l
m
n
j CML
k
l
m
n
j CLL
k
l
m
n
j Other
k
l
m
n

If other cancer, specify:

Treatments of pre-existing tumor:
Treatment date:

j Biopsy
k
l
m
n
c Surgery:
d
e
f
g

j Resection
k
l
m
n
j Limited Resection; debulking
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Chemotherapy:
d
e
f
g
Other specify:

c Radiation
d
e
f
g
Other treatment specify:

Date of recurrence (post tx):

Site(s) affected:

c Primary organ
d
e
f
g

c Regional lymph nodes
d
e
f
g

c Adjacent organs
d
e
f
g

c Distant metastases
d
e
f
g
j Immunosuppression Stopped
k
l
m
n
j Immunosuppression Reduced
k
l
m
n

Immunosuppression:

j No Immunosuppression Adjustment
k
l
m
n
Treatments of recurrent tumor:

j Biopsy
k
l
m
n
j Resection
k
l
m
n

g Surgery:
c
d
e
f

j Limited Resection; debulking
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Chemotherapy:
d
e
f
g
Other specify:

c Radiation
d
e
f
g
j Hormonal Therapy
k
l
m
n
j Interferon Alpha
k
l
m
n
j Prednisone
k
l
m
n

c Immunotherapy:
d
e
f
g

j Rituximab
k
l
m
n
j Other, specify
k
l
m
n
Other specify:
Other treatment specify:

j Alive, Free of Tumor
k
l
m
n
j Alive with Tumor
k
l
m
n

Outcome:

j Dead, due to tumor
k
l
m
n
j Dead, other causes
k
l
m
n

POST TRANSPLANT DE NOVO SOLID TUMOR
Select one or more tumor types:

c Skin, squamous cell:
d
e
f
g
Sites:
Site Location:

j Single n
k
l
m
n
j Multiple
k
l
m
c Lips/Head/Neck g
d
e
f
g
c Extremities g
d
e
f
c Trunk
d
e
f

Spread:

g None f
c
d
e
f
g Nodes f
c
d
e
g Other:
c
d
e

# of Occurrences:

Status:

Treatment Information:
Site(s) affected:

c Primary organ
d
e
f
g

c Regional lymph nodes
d
e
f
g

c Adjacent organs
d
e
f
g

c Distant metastases
d
e
f
g

Diagnosis date:

j Immunosuppression Stopped
k
l
m
n
Immunosuppression:

j Immunosuppression Reduced
k
l
m
n
j No Immunosuppression Adjustment
k
l
m
n

Specify treatment:

j Biopsy
k
l
m
n
g Surgery:
c
d
e
f

j Resection
k
l
m
n
j Limited Resection; debulking
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Cryotherapy (skin cancer)
d
e
f
g
c Chemotherapy:
d
e
f
g
Other specify:

j Hormonal Therapy
k
l
m
n
j Interferon Alpha
k
l
m
n
g Immunotherapy:
c
d
e
f

j Prednisone
k
l
m
n
j Rituximab
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Radiation
d
e
f
g
Other treatment:

j Progressive disease (PD)
k
l
m
n
j Partial response (PR)
k
l
m
n
Best treatment response:

j No treatment (NT)
k
l
m
n
j Too early in treatment to evaluate (TE)
k
l
m
n

j Stable disease (SD)
k
l
m
n
j Complete response (CR)
k
l
m
n

g Skin, basal cell:
c
d
e
f
Sites:

j Single n
k
l
m
n
j Multiple
k
l
m

Site Location:

c Lips/Head/Neck g
d
e
f
g
c Extremities g
d
e
f
c Trunk
d
e
f

Spread:

c None g
d
e
f
g
c Nodes g
d
e
f
c Other:
d
e
f

# of Occurrences:

Status:

Treatment Information:
Site(s) affected:

c Primary organ
d
e
f
g

c Regional lymph nodes
d
e
f
g

c Adjacent organs
d
e
f
g

c Distant metastases
d
e
f
g

Diagnosis date:

j Immunosuppression Stopped
k
l
m
n
Immunosuppression:

j Immunosuppression Reduced
k
l
m
n
j No Immunosuppression Adjustment
k
l
m
n

Specify treatment:

j Biopsy
k
l
m
n
c Surgery:
d
e
f
g

j Resection
k
l
m
n
j Limited Resection; debulking
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

g Cryotherapy (skin cancer)
c
d
e
f
g Chemotherapy:
c
d
e
f
Other specify:

j Hormonal Therapy
k
l
m
n
j Interferon Alpha
k
l
m
n
c Immunotherapy:
d
e
f
g

j Prednisone
k
l
m
n
j Rituximab
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Radiation
d
e
f
g

Other treatment:

j Progressive disease (PD)
k
l
m
n
j Partial response (PR)
k
l
m
n
j No treatment (NT)
k
l
m
n

Best treatment response:

j Too early in treatment to evaluate (TE)
k
l
m
n
j Stable disease (SD)
k
l
m
n
j Complete response (CR)
k
l
m
n

c Skin, melanoma:
d
e
f
g
Sites:

j Single n
k
l
m
n
j Multiple
k
l
m

Site Location:

g Lips/Head/Neck f
c
d
e
f
g Extremities f
c
d
e
g Trunk
c
d
e

Spread:

c None g
d
e
f
g
c Nodes g
d
e
f
c Other:
d
e
f

# of Occurrences:

Status:

Treatment Information:
Site(s) affected:

c Primary organ
d
e
f
g

c Regional lymph nodes
d
e
f
g

c Adjacent organs
d
e
f
g

c Distant metastases
d
e
f
g

Diagnosis date:

j Immunosuppression Stopped
k
l
m
n
Immunosuppression:

j Immunosuppression Reduced
k
l
m
n
j No Immunosuppression Adjustment
k
l
m
n

Specify treatment:

j Biopsy
k
l
m
n
g Surgery:
c
d
e
f

j Resection
k
l
m
n
j Limited Resection; debulking
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Cryotherapy (skin cancer)
d
e
f
g
c Chemotherapy:
d
e
f
g
Other specify:

j Hormonal Therapy
k
l
m
n

j Interferon Alpha
k
l
m
n
c Immunotherapy:
d
e
f
g

j Prednisone
k
l
m
n
j Rituximab
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Radiation
d
e
f
g
Other treatment:

j Progressive disease (PD)
k
l
m
n
j Partial response (PR)
k
l
m
n
Best treatment response:

j No treatment (NT)
k
l
m
n

j Too early in treatment to evaluate (TE)
k
l
m
n
j Stable disease (SD)
k
l
m
n
j Complete response (CR)
k
l
m
n

g Kaposi's sarcoma: cutaneous:
c
d
e
f
Treatment Information:
Site(s) affected:

c Primary organ
d
e
f
g

c Regional lymph nodes
d
e
f
g

c Adjacent organs
d
e
f
g

c Distant metastases
d
e
f
g

Diagnosis date:

j Immunosuppression Stopped
k
l
m
n
Immunosuppression:

j Immunosuppression Reduced
k
l
m
n

j No Immunosuppression Adjustment
k
l
m
n
Specify treatment:

j Biopsy
k
l
m
n
g Surgery:
c
d
e
f

j Resection
k
l
m
n
j Limited Resection; debulking
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Cryotherapy (skin cancer)
d
e
f
g
c Chemotherapy:
d
e
f
g
Other specify:

j Hormonal Therapy
k
l
m
n
j Interferon Alpha
k
l
m
n
g Immunotherapy:
c
d
e
f

j Prednisone
k
l
m
n
j Rituximab
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Radiation
d
e
f
g
Other treatment:

j Progressive disease (PD)
k
l
m
n
j Partial response (PR)
k
l
m
n
Best treatment response:

j No treatment (NT)
k
l
m
n
j Too early in treatment to evaluate (TE)
k
l
m
n
j Stable disease (SD)
k
l
m
n
j Complete response (CR)
k
l
m
n

g Kaposi's sarcoma: visceral:
c
d
e
f
Treatment Information:
Site(s) affected:

c Primary organ
d
e
f
g

c Regional lymph nodes
d
e
f
g

c Adjacent organs
d
e
f
g

c Distant metastases
d
e
f
g

Diagnosis date:

j Immunosuppression Stopped
k
l
m
n
Immunosuppression:

j Immunosuppression Reduced
k
l
m
n
j No Immunosuppression Adjustment
k
l
m
n

Specify treatment:

j Biopsy
k
l
m
n
g Surgery:
c
d
e
f

j Resection
k
l
m
n
j Limited Resection; debulking
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Cryotherapy (skin cancer)
d
e
f
g
c Chemotherapy:
d
e
f
g

Other specify:

j Hormonal Therapy
k
l
m
n
j Interferon Alpha
k
l
m
n
c Immunotherapy:
d
e
f
g

j Prednisone
k
l
m
n
j Rituximab
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Radiation
d
e
f
g
Other treatment:

j Progressive disease (PD)
k
l
m
n
j Partial response (PR)
k
l
m
n
Best treatment response:

j No treatment (NT)
k
l
m
n
j Too early in treatment to evaluate (TE)
k
l
m
n
j Stable disease (SD)
k
l
m
n
j Complete response (CR)
k
l
m
n

j Astrocytoma
k
l
m
n
j Medulloblastoma
k
l
m
n
j Glioblastoma Multiforme
k
l
m
n
Brain:

j Neuroblastoma
k
l
m
n
j Meningioma,Malignant
k
l
m
n
j Meningioma,Benign
k
l
m
n

j Angioblastoma
k
l
m
n
j Other Specify
k
l
m
n
Other specify:
Treatment Information:
Site(s) affected:

g Primary organ
c
d
e
f

g Regional lymph nodes
c
d
e
f

g Adjacent organs
c
d
e
f

g Distant metastases
c
d
e
f

Diagnosis date:

j Immunosuppression Stopped
k
l
m
n
Immunosuppression:

j Immunosuppression Reduced
k
l
m
n

j No Immunosuppression Adjustment
k
l
m
n
Specify treatment:

j Biopsy
k
l
m
n
g Surgery:
c
d
e
f

j Resection
k
l
m
n
j Limited Resection; debulking
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Cryotherapy (skin cancer)
d
e
f
g
c Chemotherapy:
d
e
f
g
Other specify:

j Hormonal Therapy
k
l
m
n
j Interferon Alpha
k
l
m
n
g Immunotherapy:
c
d
e
f

j Prednisone
k
l
m
n
j Rituximab
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Radiation
d
e
f
g
Other treatment:

j Progressive disease (PD)
k
l
m
n
j Partial response (PR)
k
l
m
n
Best treatment response:

j No treatment (NT)
k
l
m
n
j Too early in treatment to evaluate (TE)
k
l
m
n
j Stable disease (SD)
k
l
m
n
j Complete response (CR)
k
l
m
n

g Renal carcinoma - specify site(s):
c
d
e
f
Renal carcinoma:
Treatment Information:
Site(s) affected:

c Primary organ
d
e
f
g

c Regional lymph nodes
d
e
f
g

c Adjacent organs
d
e
f
g

c Distant metastases
d
e
f
g

Diagnosis date:

j Immunosuppression Stopped
k
l
m
n
Immunosuppression:

j Immunosuppression Reduced
k
l
m
n
j No Immunosuppression Adjustment
k
l
m
n

Specify treatment:

j Biopsy
k
l
m
n
g Surgery:
c
d
e
f

j Resection
k
l
m
n
j Limited Resection; debulking
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Cryotherapy (skin cancer)
d
e
f
g
c Chemotherapy:
d
e
f
g
Other specify:

j Hormonal Therapy
k
l
m
n
j Interferon Alpha
k
l
m
n
c Immunotherapy:
d
e
f
g

j Prednisone
k
l
m
n
j Rituximab
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Radiation
d
e
f
g
Other treatment:

j Progressive disease (PD)
k
l
m
n
j Partial response (PR)
k
l
m
n
Best treatment response:

j No treatment (NT)
k
l
m
n
j Too early in treatment to evaluate (TE)
k
l
m
n
j Stable disease (SD)
k
l
m
n
j Complete response (CR)
k
l
m
n

c Carcinoma of vulva, perineum or penis, scrotum:
d
e
f
g
Treatment Information:
Site(s) affected:

c Primary organ
d
e
f
g

c Regional lymph nodes
d
e
f
g

c Adjacent organs
d
e
f
g

c Distant metastases
d
e
f
g

Diagnosis date:

j Immunosuppression Stopped
k
l
m
n
Immunosuppression:

j Immunosuppression Reduced
k
l
m
n
j No Immunosuppression Adjustment
k
l
m
n

Specify treatment:

j Biopsy
k
l
m
n
c Surgery:
d
e
f
g

j Resection
k
l
m
n
j Limited Resection; debulking
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Cryotherapy (skin cancer)
d
e
f
g
c Chemotherapy:
d
e
f
g
Other specify:

j Hormonal Therapy
k
l
m
n
j Interferon Alpha
k
l
m
n
c Immunotherapy:
d
e
f
g

j Prednisone
k
l
m
n
j Rituximab
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

g Radiation
c
d
e
f
Other treatment:

j Progressive disease (PD)
k
l
m
n
j Partial response (PR)
k
l
m
n
Best treatment response:

j No treatment (NT)
k
l
m
n
j Too early in treatment to evaluate (TE)
k
l
m
n
j Stable disease (SD)
k
l
m
n
j Complete response (CR)
k
l
m
n

j Cervix, invasive
k
l
m
n
c Carcinoma of the uterus:
d
e
f
g

j Cervix, in situ
k
l
m
n
j Body, endometrium
k
l
m
n

Treatment Information:

Site(s) affected:

c Primary organ
d
e
f
g

c Regional lymph nodes
d
e
f
g

c Adjacent organs
d
e
f
g

c Distant metastases
d
e
f
g

Diagnosis date:

j Immunosuppression Stopped
k
l
m
n
Immunosuppression:

j Immunosuppression Reduced
k
l
m
n
j No Immunosuppression Adjustment
k
l
m
n

Specify treatment:

j Biopsy
k
l
m
n
g Surgery:
c
d
e
f

j Resection
k
l
m
n
j Limited Resection; debulking
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Cryotherapy (skin cancer)
d
e
f
g
c Chemotherapy:
d
e
f
g
Other specify:

j Hormonal Therapy
k
l
m
n
j Interferon Alpha
k
l
m
n
g Immunotherapy:
c
d
e
f

j Prednisone
k
l
m
n
j Rituximab
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Radiation
d
e
f
g
Other treatment:

j Progressive disease (PD)
k
l
m
n
j Partial response (PR)
k
l
m
n
Best treatment response:

j No treatment (NT)
k
l
m
n
j Too early in treatment to evaluate (TE)
k
l
m
n
j Stable disease (SD)
k
l
m
n
j Complete response (CR)
k
l
m
n

g Ovarian:
c
d
e
f

Treatment Information:
Site(s) affected:

g Primary organ
c
d
e
f

g Regional lymph nodes
c
d
e
f

g Adjacent organs
c
d
e
f

g Distant metastases
c
d
e
f

Diagnosis date:

j Immunosuppression Stopped
k
l
m
n
Immunosuppression:

j Immunosuppression Reduced
k
l
m
n
j No Immunosuppression Adjustment
k
l
m
n

Specify treatment:

j Biopsy
k
l
m
n
c Surgery:
d
e
f
g

j Resection
k
l
m
n
j Limited Resection; debulking
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Cryotherapy (skin cancer)
d
e
f
g
c Chemotherapy:
d
e
f
g
Other specify:

j Hormonal Therapy
k
l
m
n
j Interferon Alpha
k
l
m
n
c Immunotherapy:
d
e
f
g

j Prednisone
k
l
m
n
j Rituximab
k
l
m
n

j Other, specify
k
l
m
n
Other specify:

c Radiation
d
e
f
g
Other treatment:

j Progressive disease (PD)
k
l
m
n
j Partial response (PR)
k
l
m
n
Best treatment response:

j No treatment (NT)
k
l
m
n
j Too early in treatment to evaluate (TE)
k
l
m
n
j Stable disease (SD)
k
l
m
n
j Complete response (CR)
k
l
m
n

g Testicular:
c
d
e
f
Treatment Information:
Site(s) affected:

c Primary organ
d
e
f
g

c Regional lymph nodes
d
e
f
g

c Adjacent organs
d
e
f
g

c Distant metastases
d
e
f
g

Diagnosis date:

j Immunosuppression Stopped
k
l
m
n
Immunosuppression:

j Immunosuppression Reduced
k
l
m
n
j No Immunosuppression Adjustment
k
l
m
n

Specify treatment:

j Biopsy
k
l
m
n
g Surgery:
c
d
e
f

j Resection
k
l
m
n
j Limited Resection; debulking
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Cryotherapy (skin cancer)
d
e
f
g
c Chemotherapy:
d
e
f
g
Other specify:

j Hormonal Therapy
k
l
m
n
j Interferon Alpha
k
l
m
n
g Immunotherapy:
c
d
e
f

j Prednisone
k
l
m
n

j Rituximab
k
l
m
n
j Other, specify
k
l
m
n
Other specify:

c Radiation
d
e
f
g
Other treatment:

j Progressive disease (PD)
k
l
m
n
j Partial response (PR)
k
l
m
n
Best treatment response:

j No treatment (NT)
k
l
m
n
j Too early in treatment to evaluate (TE)
k
l
m
n
j Stable disease (SD)
k
l
m
n

j Complete response (CR)
k
l
m
n

c Esophagus:
d
e
f
g
Treatment Information:
Site(s) affected:

c Primary organ
d
e
f
g

c Regional lymph nodes
d
e
f
g

c Adjacent organs
d
e
f
g

c Distant metastases
d
e
f
g

Diagnosis date:

j Immunosuppression Stopped
k
l
m
n
Immunosuppression:

j Immunosuppression Reduced
k
l
m
n
j No Immunosuppression Adjustment
k
l
m
n

Specify treatment:

j Biopsy
k
l
m
n
c Surgery:
d
e
f
g

j Resection
k
l
m
n
j Limited Resection; debulking
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Cryotherapy (skin cancer)
d
e
f
g
c Chemotherapy:
d
e
f
g
Other specify:

j Hormonal Therapy
k
l
m
n
j Interferon Alpha
k
l
m
n

g Immunotherapy:
c
d
e
f

j Prednisone
k
l
m
n
j Rituximab
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Radiation
d
e
f
g
Other treatment:

j Progressive disease (PD)
k
l
m
n
Best treatment response:

j Partial response (PR)
k
l
m
n
j No treatment (NT)
k
l
m
n
j Too early in treatment to evaluate (TE)
k
l
m
n

j Stable disease (SD)
k
l
m
n
j Complete response (CR)
k
l
m
n

g Stomach:
c
d
e
f
Treatment Information:
Site(s) affected:

c Primary organ
d
e
f
g

c Regional lymph nodes
d
e
f
g

c Adjacent organs
d
e
f
g

c Distant metastases
d
e
f
g

Diagnosis date:

j Immunosuppression Stopped
k
l
m
n
Immunosuppression:

j Immunosuppression Reduced
k
l
m
n
j No Immunosuppression Adjustment
k
l
m
n

Specify treatment:

j Biopsy
k
l
m
n
g Surgery:
c
d
e
f

j Resection
k
l
m
n
j Limited Resection; debulking
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Cryotherapy (skin cancer)
d
e
f
g
c Chemotherapy:
d
e
f
g
Other specify:

j Hormonal Therapy
k
l
m
n

j Interferon Alpha
k
l
m
n
g Immunotherapy:
c
d
e
f

j Prednisone
k
l
m
n
j Rituximab
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Radiation
d
e
f
g
Other treatment:

j Progressive disease (PD)
k
l
m
n
j Partial response (PR)
k
l
m
n
j No treatment (NT)
k
l
m
n

j Too early in treatment to evaluate (TE)
k
l
m
n
Best treatment response:

j Stable disease (SD)
k
l
m
n
j Complete response (CR)
k
l
m
n

g Small intestine:
c
d
e
f
Treatment Information:
Site(s) affected:

c Primary organ
d
e
f
g

c Regional lymph nodes
d
e
f
g

c Adjacent organs
d
e
f
g

c Distant metastases
d
e
f
g

Diagnosis date:

j Immunosuppression Stopped
k
l
m
n
Immunosuppression:

j Immunosuppression Reduced
k
l
m
n
j No Immunosuppression Adjustment
k
l
m
n

Specify treatment:

j Biopsy
k
l
m
n
g Surgery:
c
d
e
f

j Resection
k
l
m
n
j Limited Resection; debulking
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Cryotherapy (skin cancer)
d
e
f
g
c Chemotherapy:
d
e
f
g
Other specify:

j Hormonal Therapy
k
l
m
n
j Interferon Alpha
k
l
m
n
g Immunotherapy:
c
d
e
f

j Prednisone
k
l
m
n
j Rituximab
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Radiation
d
e
f
g
Other treatment:

j Progressive disease (PD)
k
l
m
n
j Partial response (PR)
k
l
m
n

j No treatment (NT)
k
l
m
n
Best treatment response:

j Too early in treatment to evaluate (TE)
k
l
m
n
j Stable disease (SD)
k
l
m
n
j Complete response (CR)
k
l
m
n

g Pancreas:
c
d
e
f
Treatment Information:
Site(s) affected:

c Primary organ
d
e
f
g

c Regional lymph nodes
d
e
f
g

c Adjacent organs
d
e
f
g

c Distant metastases
d
e
f
g

Diagnosis date:

j Immunosuppression Stopped
k
l
m
n
Immunosuppression:

j Immunosuppression Reduced
k
l
m
n
j No Immunosuppression Adjustment
k
l
m
n

Specify treatment:

j Biopsy
k
l
m
n
g Surgery:
c
d
e
f

j Resection
k
l
m
n
j Limited Resection; debulking
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Cryotherapy (skin cancer)
d
e
f
g
c Chemotherapy:
d
e
f
g
Other specify:

j Hormonal Therapy
k
l
m
n
j Interferon Alpha
k
l
m
n
g Immunotherapy:
c
d
e
f

j Prednisone
k
l
m
n
j Rituximab
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Radiation
d
e
f
g
Other treatment:

j Progressive disease (PD)
k
l
m
n

j Partial response (PR)
k
l
m
n
j No treatment (NT)
k
l
m
n
Best treatment response:

j Too early in treatment to evaluate (TE)
k
l
m
n
j Stable disease (SD)
k
l
m
n
j Complete response (CR)
k
l
m
n

g Larynx:
c
d
e
f
Treatment Information:
Site(s) affected:

c Primary organ
d
e
f
g

c Regional lymph nodes
d
e
f
g

c Adjacent organs
d
e
f
g

c Distant metastases
d
e
f
g

Diagnosis date:

j Immunosuppression Stopped
k
l
m
n
Immunosuppression:

j Immunosuppression Reduced
k
l
m
n
j No Immunosuppression Adjustment
k
l
m
n

Specify treatment:

j Biopsy
k
l
m
n
g Surgery:
c
d
e
f

j Resection
k
l
m
n
j Limited Resection; debulking
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Cryotherapy (skin cancer)
d
e
f
g
c Chemotherapy:
d
e
f
g
Other specify:

j Hormonal Therapy
k
l
m
n
j Interferon Alpha
k
l
m
n
c Immunotherapy:
d
e
f
g

j Prednisone
k
l
m
n
j Rituximab
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Radiation
d
e
f
g
Other treatment:

j Progressive disease (PD)
k
l
m
n
j Partial response (PR)
k
l
m
n
Best treatment response:

j No treatment (NT)
k
l
m
n
j Too early in treatment to evaluate (TE)
k
l
m
n
j Stable disease (SD)
k
l
m
n
j Complete response (CR)
k
l
m
n

c Tongue, throat:
d
e
f
g
Treatment Information:
Site(s) affected:

c Primary organ
d
e
f
g

c Regional lymph nodes
d
e
f
g

c Adjacent organs
d
e
f
g

c Distant metastases
d
e
f
g

Diagnosis date:

j Immunosuppression Stopped
k
l
m
n
Immunosuppression:

j Immunosuppression Reduced
k
l
m
n
j No Immunosuppression Adjustment
k
l
m
n

Specify treatment:

j Biopsy
k
l
m
n
g Surgery:
c
d
e
f

j Resection
k
l
m
n
j Limited Resection; debulking
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Cryotherapy (skin cancer)
d
e
f
g
c Chemotherapy:
d
e
f
g
Other specify:

j Hormonal Therapy
k
l
m
n
j Interferon Alpha
k
l
m
n
c Immunotherapy:
d
e
f
g

j Prednisone
k
l
m
n
j Rituximab
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Radiation
d
e
f
g

Other treatment:

j Progressive disease (PD)
k
l
m
n
j Partial response (PR)
k
l
m
n
Best treatment response:

j No treatment (NT)
k
l
m
n
j Too early in treatment to evaluate (TE)
k
l
m
n
j Stable disease (SD)
k
l
m
n
j Complete response (CR)
k
l
m
n

c Thyroid:
d
e
f
g
Treatment Information:
Site(s) affected:

c Primary organ
d
e
f
g

c Regional lymph nodes
d
e
f
g

c Adjacent organs
d
e
f
g

c Distant metastases
d
e
f
g

Diagnosis date:

j Immunosuppression Stopped
k
l
m
n
Immunosuppression:

j Immunosuppression Reduced
k
l
m
n
j No Immunosuppression Adjustment
k
l
m
n

Specify treatment:

j Biopsy
k
l
m
n
c Surgery:
d
e
f
g

j Resection
k
l
m
n
j Limited Resection; debulking
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Cryotherapy (skin cancer)
d
e
f
g
c Chemotherapy:
d
e
f
g
Other specify:

j Hormonal Therapy
k
l
m
n
j Interferon Alpha
k
l
m
n
c Immunotherapy:
d
e
f
g

j Prednisone
k
l
m
n
j Rituximab
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

g Radiation
c
d
e
f
Other treatment:

j Progressive disease (PD)
k
l
m
n
j Partial response (PR)
k
l
m
n
Best treatment response:

j No treatment (NT)
k
l
m
n
j Too early in treatment to evaluate (TE)
k
l
m
n
j Stable disease (SD)
k
l
m
n
j Complete response (CR)
k
l
m
n

c Bladder:
d
e
f
g
Treatment Information:
Site(s) affected:

c Primary organ
d
e
f
g

c Regional lymph nodes
d
e
f
g

c Adjacent organs
d
e
f
g

c Distant metastases
d
e
f
g

Diagnosis date:

j Immunosuppression Stopped
k
l
m
n
Immunosuppression:

j Immunosuppression Reduced
k
l
m
n
j No Immunosuppression Adjustment
k
l
m
n

Specify treatment:

j Biopsy
k
l
m
n
c Surgery:
d
e
f
g

j Resection
k
l
m
n
j Limited Resection; debulking
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Cryotherapy (skin cancer)
d
e
f
g
c Chemotherapy:
d
e
f
g
Other specify:

j Hormonal Therapy
k
l
m
n
j Interferon Alpha
k
l
m
n
c Immunotherapy:
d
e
f
g

j Prednisone
k
l
m
n
j Rituximab
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Radiation
d
e
f
g
Other treatment:

j Progressive disease (PD)
k
l
m
n
j Partial response (PR)
k
l
m
n
Best treatment response:

j No treatment (NT)
k
l
m
n
j Too early in treatment to evaluate (TE)
k
l
m
n
j Stable disease (SD)
k
l
m
n
j Complete response (CR)
k
l
m
n

g Breast:
c
d
e
f
Treatment Information:
Site(s) affected:

c Primary organ
d
e
f
g

c Regional lymph nodes
d
e
f
g

c Adjacent organs
d
e
f
g

c Distant metastases
d
e
f
g

Diagnosis date:

j Immunosuppression Stopped
k
l
m
n
Immunosuppression:

j Immunosuppression Reduced
k
l
m
n
j No Immunosuppression Adjustment
k
l
m
n

Specify treatment:

j Biopsy
k
l
m
n
g Surgery:
c
d
e
f

j Resection
k
l
m
n

j Limited Resection; debulking
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Cryotherapy (skin cancer)
d
e
f
g
c Chemotherapy:
d
e
f
g
Other specify:

j Hormonal Therapy
k
l
m
n
j Interferon Alpha
k
l
m
n
c Immunotherapy:
d
e
f
g

j Prednisone
k
l
m
n
j Rituximab
k
l
m
n

j Other, specify
k
l
m
n
Other specify:

c Radiation
d
e
f
g
Other treatment:

j Progressive disease (PD)
k
l
m
n
j Partial response (PR)
k
l
m
n
Best treatment response:

j No treatment (NT)
k
l
m
n
j Too early in treatment to evaluate (TE)
k
l
m
n
j Stable disease (SD)
k
l
m
n
j Complete response (CR)
k
l
m
n

c Prostate:
d
e
f
g
Treatment Information:
Site(s) affected:

c Primary organ
d
e
f
g

c Regional lymph nodes
d
e
f
g

c Adjacent organs
d
e
f
g

c Distant metastases
d
e
f
g

Diagnosis date:

j Immunosuppression Stopped
k
l
m
n
Immunosuppression:

j Immunosuppression Reduced
k
l
m
n
j No Immunosuppression Adjustment
k
l
m
n

Specify treatment:

j Biopsy
k
l
m
n
c Surgery:
d
e
f
g

j Resection
k
l
m
n
j Limited Resection; debulking
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

g Cryotherapy (skin cancer)
c
d
e
f
c Chemotherapy:
d
e
f
g
Other specify:

j Hormonal Therapy
k
l
m
n
c Immunotherapy:
d
e
f
g

j Interferon Alpha
k
l
m
n
j Prednisone
k
l
m
n

j Rituximab
k
l
m
n
j Other, specify
k
l
m
n
Other specify:

c Radiation
d
e
f
g
Other treatment:

j Progressive disease (PD)
k
l
m
n
j Partial response (PR)
k
l
m
n
Best treatment response:

j No treatment (NT)
k
l
m
n
j Too early in treatment to evaluate (TE)
k
l
m
n
j Stable disease (SD)
k
l
m
n

j Complete response (CR)
k
l
m
n

Dukes classification:

j A
k
l
m
n
c Colo-rectal:
d
e
f
g

j B
k
l
m
n
j C
k
l
m
n
j Unknown
k
l
m
n

Treatment Information:
Site(s) affected:

g Primary organ
c
d
e
f

g Regional lymph nodes
c
d
e
f

c Adjacent organs
d
e
f
g

c Distant metastases
d
e
f
g

Diagnosis date:

j Immunosuppression Stopped
k
l
m
n
Immunosuppression:

j Immunosuppression Reduced
k
l
m
n
j No Immunosuppression Adjustment
k
l
m
n

Specify treatment:

j Biopsy
k
l
m
n
c Surgery:
d
e
f
g

j Resection
k
l
m
n
j Limited Resection; debulking
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Cryotherapy (skin cancer)
d
e
f
g

g Chemotherapy:
c
d
e
f
Other specify:

j Hormonal Therapy
k
l
m
n
j Interferon Alpha
k
l
m
n
c Immunotherapy:
d
e
f
g

j Prednisone
k
l
m
n
j Rituximab
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Radiation
d
e
f
g
Other treatment:

j Progressive disease (PD)
k
l
m
n
j Partial response (PR)
k
l
m
n
Best treatment response:

j No treatment (NT)
k
l
m
n
j Too early in treatment to evaluate (TE)
k
l
m
n
j Stable disease (SD)
k
l
m
n
j Complete response (CR)
k
l
m
n

c Primary hepatic tumor:
d
e
f
g
j Hepatocellular Carcinoma
k
l
m
n
j Cholangiocarcinoma
k
l
m
n
Specify type:

j Epithelioid-Hemangio-Endothelioma
k
l
m
n
j Hepatoblastoma
k
l
m
n

j Hemangiosarcoma
k
l
m
n
j Other
k
l
m
n
Other specify:
Treatment Information:
Site(s) affected:

g Primary organ
c
d
e
f

g Regional lymph nodes
c
d
e
f

g Adjacent organs
c
d
e
f

g Distant metastases
c
d
e
f

Diagnosis date:

j Immunosuppression Stopped
k
l
m
n
Immunosuppression:

j Immunosuppression Reduced
k
l
m
n

j No Immunosuppression Adjustment
k
l
m
n
Specify treatment:

j Biopsy
k
l
m
n
g Surgery:
c
d
e
f

j Resection
k
l
m
n
j Limited Resection; debulking
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Cryotherapy (skin cancer)
d
e
f
g
c Chemotherapy:
d
e
f
g
Other specify:

j Hormonal Therapy
k
l
m
n
j Interferon Alpha
k
l
m
n
g Immunotherapy:
c
d
e
f

j Prednisone
k
l
m
n
j Rituximab
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Radiation
d
e
f
g
Other treatment:

j Progressive disease (PD)
k
l
m
n
j Partial response (PR)
k
l
m
n
Best treatment response:

j No treatment (NT)
k
l
m
n
j Too early in treatment to evaluate (TE)
k
l
m
n
j Stable disease (SD)
k
l
m
n
j Complete response (CR)
k
l
m
n

g Metastatic liver tumor:
c
d
e
f
j Stomach Adenocarcinoma
k
l
m
n
j Colon Adenocarcinoma
k
l
m
n
Specify original site:

j Breast Carcinoma
k
l
m
n
j Pancreas Carcinoma
k
l
m
n
j Bronchial Carcinoma
k
l
m
n

j Carcinoid (Neuroendocrine)
k
l
m
n
j Other
k
l
m
n
Other specify:
Treatment Information:
Site(s) affected:

g Primary organ
c
d
e
f

g Regional lymph nodes
c
d
e
f

g Adjacent organs
c
d
e
f

g Distant metastases
c
d
e
f

Diagnosis date:

j Immunosuppression Stopped
k
l
m
n
Immunosuppression:

j Immunosuppression Reduced
k
l
m
n

j No Immunosuppression Adjustment
k
l
m
n
Specify treatment:

j Biopsy
k
l
m
n
c Surgery:
d
e
f
g

j Resection
k
l
m
n
j Limited Resection; debulking
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Cryotherapy (skin cancer)
d
e
f
g
c Chemotherapy:
d
e
f
g
Other specify:

j Hormonal Therapy
k
l
m
n
j Interferon Alpha
k
l
m
n
c Immunotherapy:
d
e
f
g

j Prednisone
k
l
m
n
j Rituximab
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Radiation
d
e
f
g
Other treatment:

j Progressive disease (PD)
k
l
m
n
Best treatment response:

j Partial response (PR)
k
l
m
n

j No treatment (NT)
k
l
m
n

j Too early in treatment to evaluate (TE)
k
l
m
n
j Stable disease (SD)
k
l
m
n
j Complete response (CR)
k
l
m
n

c Lung:
d
e
f
g

j Small cell n
k
l
m
n
j Non-small cell
k
l
m

Treatment Information:
Site(s) affected:

c Primary organ
d
e
f
g

c Regional lymph nodes
d
e
f
g

c Adjacent organs
d
e
f
g

c Distant metastases
d
e
f
g

Diagnosis date:

j Immunosuppression Stopped
k
l
m
n
Immunosuppression:

j Immunosuppression Reduced
k
l
m
n
j No Immunosuppression Adjustment
k
l
m
n

Specify treatment:

j Biopsy
k
l
m
n
c Surgery:
d
e
f
g

j Resection
k
l
m
n
j Limited Resection; debulking
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Cryotherapy (skin cancer)
d
e
f
g
c Chemotherapy:
d
e
f
g
Other specify:

j Hormonal Therapy
k
l
m
n
j Interferon Alpha
k
l
m
n
g Immunotherapy:
c
d
e
f

j Prednisone
k
l
m
n
j Rituximab
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Radiation
d
e
f
g
Other treatment:

j Progressive disease (PD)
k
l
m
n

j Partial response (PR)
k
l
m
n
j No treatment (NT)
k
l
m
n
Best treatment response:

j Too early in treatment to evaluate (TE)
k
l
m
n
j Stable disease (SD)
k
l
m
n
j Complete response (CR)
k
l
m
n

j AML
k
l
m
n
j ALL
k
l
m
n
c Leukemia:
d
e
f
g

j MDS
k
l
m
n
j CML
k
l
m
n
j CLL
k
l
m
n

j Other
k
l
m
n
Treatment Information:
Site(s) affected:

c Primary organ
d
e
f
g

c Regional lymph nodes
d
e
f
g

c Adjacent organs
d
e
f
g

c Distant metastases
d
e
f
g

Diagnosis date:

j Immunosuppression Stopped
k
l
m
n
Immunosuppression:

j Immunosuppression Reduced
k
l
m
n
j No Immunosuppression Adjustment
k
l
m
n

Specify treatment:

j Biopsy
k
l
m
n
g Surgery:
c
d
e
f

j Resection
k
l
m
n
j Limited Resection; debulking
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Cryotherapy (skin cancer)
d
e
f
g
c Chemotherapy:
d
e
f
g
Other specify:

j Hormonal Therapy
k
l
m
n
g Immunotherapy:
c
d
e
f

j Interferon Alpha
k
l
m
n

j Prednisone
k
l
m
n
j Rituximab
k
l
m
n
j Other, specify
k
l
m
n
Other specify:

c Radiation
d
e
f
g
Other treatment:

j Progressive disease (PD)
k
l
m
n
j Partial response (PR)
k
l
m
n
Best treatment response:

j No treatment (NT)
k
l
m
n
j Too early in treatment to evaluate (TE)
k
l
m
n

j Stable disease (SD)
k
l
m
n
j Complete response (CR)
k
l
m
n

c Sarcomas:
d
e
f
g
Site(s):
Specify type:
Other specify:
Treatment Information:
Site(s) affected:

c Primary organ
d
e
f
g

c Regional lymph nodes
d
e
f
g

c Adjacent organs
d
e
f
g

c Distant metastases
d
e
f
g

Diagnosis date:

j Immunosuppression Stopped
k
l
m
n
Immunosuppression:

j Immunosuppression Reduced
k
l
m
n
j No Immunosuppression Adjustment
k
l
m
n

Specify treatment:

j Biopsy
k
l
m
n
c Surgery:
d
e
f
g

j Resection
k
l
m
n
j Limited Resection; debulking
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Cryotherapy (skin cancer)
d
e
f
g

g Chemotherapy:
c
d
e
f
Other specify:

j Hormonal Therapy
k
l
m
n
j Interferon Alpha
k
l
m
n
c Immunotherapy:
d
e
f
g

j Prednisone
k
l
m
n
j Rituximab
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Radiation
d
e
f
g
Other treatment:

j Progressive disease (PD)
k
l
m
n
j Partial response (PR)
k
l
m
n
Best treatment response:

j No treatment (NT)
k
l
m
n
j Too early in treatment to evaluate (TE)
k
l
m
n
j Stable disease (SD)
k
l
m
n
j Complete response (CR)
k
l
m
n

c Other cancers:
d
e
f
g
Site(s):
Specify type:
Treatment Information:
Site(s) affected:

c Primary organ
d
e
f
g

c Regional lymph nodes
d
e
f
g

c Adjacent organs
d
e
f
g

c Distant metastases
d
e
f
g

Diagnosis date:

j Immunosuppression Stopped
k
l
m
n
Immunosuppression:

j Immunosuppression Reduced
k
l
m
n
j No Immunosuppression Adjustment
k
l
m
n

Specify treatment:

j Biopsy
k
l
m
n
c Surgery:
d
e
f
g

j Resection
k
l
m
n
j Limited Resection; debulking
k
l
m
n

j Other, specify
k
l
m
n
Other specify:

c Cryotherapy (skin cancer)
d
e
f
g
c Chemotherapy:
d
e
f
g
Other specify:

j Hormonal Therapy
k
l
m
n
j Interferon Alpha
k
l
m
n
c Immunotherapy:
d
e
f
g

j Prednisone
k
l
m
n
j Rituximab
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Radiation
d
e
f
g
Other treatment:

j Progressive disease (PD)
k
l
m
n
j Partial response (PR)
k
l
m
n
Best treatment response:

j No treatment (NT)
k
l
m
n
j Too early in treatment to evaluate (TE)
k
l
m
n
j Stable disease (SD)
k
l
m
n
j Complete response (CR)
k
l
m
n

c Primary unknown:
d
e
f
g
Treatment Information:
Site(s) affected:

c Primary organ
d
e
f
g

c Regional lymph nodes
d
e
f
g

c Adjacent organs
d
e
f
g

c Distant metastases
d
e
f
g

Diagnosis date:

j Immunosuppression Stopped
k
l
m
n
Immunosuppression:

j Immunosuppression Reduced
k
l
m
n
j No Immunosuppression Adjustment
k
l
m
n

Specify treatment:

j Biopsy
k
l
m
n
j Resection
k
l
m
n

c Surgery:
d
e
f
g

j Limited Resection; debulking
k
l
m
n
j Other, specify
k
l
m
n

Other specify:

c Cryotherapy (skin cancer)
d
e
f
g
c Chemotherapy:
d
e
f
g
Other specify:

j Hormonal Therapy
k
l
m
n
j Interferon Alpha
k
l
m
n
c Immunotherapy:
d
e
f
g

j Prednisone
k
l
m
n
j Rituximab
k
l
m
n

j Other, specify
k
l
m
n
Other specify:

c Radiation
d
e
f
g
Other treatment:

j Progressive disease (PD)
k
l
m
n
j Partial response (PR)
k
l
m
n
Best treatment response:

j No treatment (NT)
k
l
m
n
j Too early in treatment to evaluate (TE)
k
l
m
n
j Stable disease (SD)
k
l
m
n
j Complete response (CR)
k
l
m
n

j Alive, Free of Tumor
k
l
m
n
Outcome:

j Alive with Tumor
k
l
m
n
j Dead, due to tumor
k
l
m
n
j Dead, other causes
k
l
m
n

POST TX LYMPHOPROLIFERATIVE DISEASE AND LYMPHOMA
Diagnosis date:

j Polymorphic Hyperplasia
k
l
m
n
j Polymorphic PTLD(lymphoma)
k
l
m
n
Pathology:

j Monomorphic PTLD(lymphoma)
k
l
m
n
j Mutiple Myeloma, Plasmacytoma
k
l
m
n

j Hodgkin's Disease
k
l
m
n
j Other, Specify
k
l
m
n
Other Specify:

j Monoclonal
k
l
m
n
Clonality:

j Polyclonal
k
l
m
n
j Oligoclonal
k
l
m
n
j Unknown
k
l
m
n
j B Cell
k
l
m
n

Predominant cell type:

j T Cell
k
l
m
n
j Other Specify
k
l
m
n
j Unknown
k
l
m
n

Other specify:

Epstein-Barr virus (EBV) status of tumor:

j EBV positive n
k
l
m
n
j EBV negative n
k
l
m
j Unknown
k
l
m

Anatomy:

j Single site n
k
l
m
n
j Multiple sites
k
l
m

Lymph Nodes:

j YES n
k
l
m
n
j NO
k
l
m

Gastrointestinal

c Allograft
d
e
f
g

c Stomach
d
e
f
g

c Lung
d
e
f
g

c Small intestine
d
e
f
g

g Bone marrow
c
d
e
f

c Colon
d
e
f
g

c CNS
d
e
f
g
c Liver
d
e
f
g

Other specify:

Ann Arbor stage:

j I n
k
l
m
n
j II n
k
l
m
j III n
k
l
m
j IV n
k
l
m
j Unknown
k
l
m

PTLD Treatment
Abbreviations: PD-Progressive disease PR=Partial response SD-Stable disease CR-Complete response
1. Reduction/Cessation of immunosuppression:

Best response:

2. Surgery

j YES n
k
l
m
n
j NO
k
l
m
j SD n
k
l
m
j PD n
k
l
m
n
j PR n
k
l
m
j CR
k
l
m

j Biopsy
k
l
m
n
j Resection
k
l
m
n
Type:

j Limited Resection; debulking
k
l
m
n
j No Surgery
k
l
m
n
j Other, specify
k
l
m
n

Other specify:
Best response:

3. Anti-viral therapy:

j SD n
k
l
m
j PD n
k
l
m
n
j PR n
k
l
m
j CR
k
l
m

j YES n
k
l
m
n
j NO
k
l
m
j Acyclovir
k
l
m
n
j Cytogam
k
l
m
n
j Cytovene
k
l
m
n

Drug 1:

j Foscarnet
k
l
m
n
j Ganciclovir
k
l
m
n
j IVIG
k
l
m
n
j Valtrex
k
l
m
n
j Other, specify
k
l
m
n

Other specify:
Best response:

j SD n
k
l
m
j PD n
k
l
m
n
j PR n
k
l
m
j CR
k
l
m

j Acyclovir
k
l
m
n
j Cytogam
k
l
m
n
j Cytovene
k
l
m
n
Drug 2:

j Foscarnet
k
l
m
n
j Ganciclovir
k
l
m
n
j IVIG
k
l
m
n
j Valtrex
k
l
m
n
j Other, specify
k
l
m
n

Other specify:
Best response:

4. Chemotherapy:

j SD n
k
l
m
j PD n
k
l
m
n
j PR n
k
l
m
j CR
k
l
m

j YES n
k
l
m
n
j NO
k
l
m

Drug/Regimen 1:
Other specify:
Best response:

j SD n
k
l
m
j PD n
k
l
m
n
j PR n
k
l
m
j CR
k
l
m

Drug/Regimen 2:
Other specify:
Best response:

5. Radiation therapy:

Best Response:

6. Immunotherapy:

j SD n
k
l
m
j PD n
k
l
m
n
j PR n
k
l
m
j CR
k
l
m

j YES n
k
l
m
n
j NO
k
l
m
j SD n
k
l
m
j PD n
k
l
m
n
j PR n
k
l
m
j CR
k
l
m

j YES n
k
l
m
n
j NO
k
l
m
j Hormonal Therapy
k
l
m
n
j Interferon Alpha
k
l
m
n

Type:

j Prednisone
k
l
m
n
j Rituximab
k
l
m
n
j Other, specify
k
l
m
n

Other specify:
Best response:

j SD n
k
l
m
j PD n
k
l
m
n
j PR n
k
l
m
j CR
k
l
m