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pdfPre-Transplant Essential Data
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OMB No: 0915-0310
Expiration Date: 7/31/2016
Public Burden Statement: An agency may not conduct or sponsor, and a person is
not required to respond to, a collection of information unless it displays a currently valid
OMB control number. The OMB control number for this project is 0915-0310. Public
reporting burden for this collection of information is estimated to average 1.0 hours per
response, including the time for reviewing instructions, searching existing data sources,
and completing and reviewing the collection of information. Send comments regarding
this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers
Lane, Room 10-29, Rockville, Maryland, 20857.
CIBMTR Use Only
Sequence Number:
Date Received:
Center Identification
CIBMTR Center Number: ___ ___ ___ ___ ___
EBMT Code (CIC): ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Hospital: __________________________________________________
Unit: (check only one)
☐ Adult
☐ Pediatric
Recipient Identification
CIBMTR Recipient ID (CRID): ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
CIBMTR Form 2400 revision 4 (page 1 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Recipient Data
1.
Date of birth: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
2. Sex:
☐ Male
☐ Female
3. Ethnicity:
☐ Hispanic or Latino
☐ Not Hispanic or Latino
☐ Not applicable (not a resident of the USA)
4.
Race: ☐ White
Copy question 4 to report more than one race.
5.
Zip or postal code for place of recipient’s residence (USA recipients only): __ __ __ __ __
6.
Is the recipient participating in a clinical trial?
☐ Native Hawaiian or Other Pacific Islander
☐ Yes
☐ No
7.
☐ Unknown
☐ Black or African American ☐ Asian
☐ American Indian or Alaska Native
☐ Not reported
☐ Unknown
Study Sponsor:
☐ BMT-CTN
☐ RCI-BMT
☐ USIDNET
☐ COG
☐ Other sponsor
9.
Study ID Number:________________________
8.
Specify other sponsor:_____________________
10. Subject ID:_________________________
Copy questions 7-10 to report participation in more than one study.
Hematopoietic Cellular Transplant (HCT)
11. Date of this HCT: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
12. Was this the first HCT for this recipient?
☐ Yes
☐ Yes
☐ No
13. Is a subsequent HCT planned as part of the overall treatment protocol (not as a
reaction to post-HCT disease assessment)? (For autologous HCTs only)
☐ No
15.
14.
Specify subsequent HCT planned:
☐ Autologous ☐ Allogeneic
Specify the number of prior HCTs: ___ ___
Specify the HSC source(s) for all prior HCTs:
16. Autologous
17.
Allogeneic, unrelated
18.
Allogeneic, related
19. Syngeneic
20. Date of the last HCT (just before current HCT):
CIBMTR Form 2400 revision 4 (page 2 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ No
☐ No
☐ No
☐ No
__ __ __ __ / __ __ / __ __
YYYY
MM
DD
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
21. Was the last HCT performed at a different institution?
☐ Yes
☐ No
Specify the institution that performed the last HCT:
22. Name:______________________________________________
City:________________________________________________
State:______________________________________________
Country:____________________________________________
23. What was the HSC source for the last HCT?
☐ Autologous
24.
☐ Allogeneic, unrelated donor
☐ Allogeneic, related donor
Reason for current HCT:
☐ No hematopoietic recovery
☐ Partial hematopoietic recovery
☐ Graft failure/rejection after achieving initial hematopoietic recovery_
25. Date of graft failure/rejection: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
☐ Persistent primary disease
☐ Recurrent primary disease
26. Date of relapse: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
☐ Planned second HCT, per protocol
☐ New malignancy (including PTLD and EBV lymphoma)
27. Date of secondary malignancy: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
☐ Stable, mixed chimerism
☐ Declining chimerism
☐ Other
28. Specify other reason: __________________________________
Donor Information
29. Multiple donors?
☐ Yes
☐ No
30. Specify number of donors: ___ ___
To report more than one donor, copy questions 31- 62 and complete for each donor.
31. Specify donor:
☐ Autologous - Go to question 46
☐ Autologous cord blood unit - Go to question 35
☐ NMDP unrelated cord blood unit - Go to question 32
☐ NMDP unrelated donor - Go to question 33
☐ Related donor - Go to question 40
☐ Related cord blood unit - Go to question 35
☐ Non-NMDP unrelated donor - Go to question 34
☐ Non-NMDP unrelated cord blood unit - Go to question 35
CIBMTR Form 2400 revision 4 (page 3 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
32. NMDP cord blood unit ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ - Go to question 46
33. NMDP donor ID: ___ ___ ___ ___ - ___ ___ ___ ___ - ___ - Go to question 46
34. Non-NMDP unrelated donor ID: (not applicable for related donors)
___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ - Go to question 38
35. Non-NMDP cord blood unit ID: (include related and autologous CBUs)
___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
36.
Is the CBU ID also the ISBT DIN number?
☐ Yes
☐ No
37. Specify the ISBT DIN number: ____________________________________________
38. Registry or UCB Bank ID: ___ ___ ___ ___ - If ‘Other registry’ go to 39, otherwise go to question 41
39. Specify other Registry or UCB Bank: _________________________________ - Go to question 41
40. Specify the related donor type:
☐ Syngeneic (monozygotic twin)
☐ HLA-identical sibling (may include non-monozygotic twin)
☐ HLA-matched other relative
☐ HLA-mismatched relative
41. Date of birth: (donor/infant)
☐ Known
☐ Unknown
42.
Date of birth: (donor/infant): __ __ __ __ / __ __ / __ __
YYYY
MM
DD
43.
Age: (donor/infant)
☐ Known 44. Age: (donor/infant) ___ ___
☐ Unknown ☐ Months (use only if less than 1
45. Sex: (donor/infant)
Specify product type:
46. Bone marrow:
47. PBSC:
48. Single cord blood unit:
49. Other product:
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ No
☐ Male
year old)
☐ Years
☐ Female
☐ No
☐ No
☐ No
50. Specify other product type:______________________________________________
A series of collections should be considered a single product when they are all from the same donor and use the same collection method
and technique (and mobilization, if applicable), even if the collections are performed on different days.
51. Specify number of products infused from this donor: ___ ___
Questions 52 – 59 are for autologous HCT recipients only. If other than autologous skip to question 60
52. Did the recipient have more than one mobilization event to acquire cells for HCT?
☐ Yes
☐ No
53. Specify the total number of mobilization events performed for this HCT (regardless of
the number of collections or which collections were used for this HCT): ___
CIBMTR Form 2400 revision 4 (page 4 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Specify all agents used in the mobilization events reported above:
54. G-CSF
55. GM-CSF
56. Pegylated G-CSF
57. Plerixafor (Mozobil)
58. Other CXCR4 inhibitor
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
59. Combined with chemotherapy:
☐ No
☐ No
☐ No
☐ No
☐ No
☐ Yes
☐ No
60. Was this donor used for any prior HCTs? ☐ Yes
☐ No
61. Donor CMV-antibodies (IgG or Total) (Allogeneic HCTs only)
☐ Reactive
☐ Non-reactive
☐ Not done
☐ Not applicable (cord blood unit)
62. Was plerixafor (Mozobil) given at any time prior to the preparative regimen? (Related HCTs only) ☐ Yes
☐ No
☐ Unknown
Consent
63. Has the recipient signed an IRB-approved consent form for submitting research data to the NMDP/CIBMTR?
☐ Yes (patient consented)
☐ No (patient declined)
☐ Not approached
64. Date form was signed: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
65. Did the recipient give permission to be directly contacted for future research?
☐ Yes (patient provided permission)
☐ No (patient declined)
☐ Not approached
66. Date form was signed: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
67. Has the recipient signed an IRB-approved consent form to donate research blood samples to the NMDP/CIBMTR?
☐ Yes (patient consented)
☐ No (patient declined)
☐ Not approached
☐ Not applicable (center not participating)
68. Date form was signed: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
69. Has the donor signed an IRB-approved consent form to donate research blood samples to the NMDP/CIBMTR? (Related donors only)
☐ Yes (donor consented)
☐ No (donor declined)
☐ Not approached
☐ Not applicable (center not participating)
70. Date form was signed: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
Product Processing/Manipulation
71. Was the product manipulated prior to infusion?
☐ Yes
☐ No
72. Specify portion manipulated:
☐ Entire product
☐ Portion of product
Specify all methods used to manipulate the product:
73. Washed
74. Diluted
75. Buffy coat enriched (buffy coat preparation)
CIBMTR Form 2400 revision 4 (page 5 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
☐ Yes
☐ Yes
☐ Yes
☐ No
☐ No
☐ No
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
76. B-cell reduced
77. CD8 reduced
78. Plasma reduced (removal)
79. RBC reduced
80. Cultured (ex-vivo expansion)
81. Genetic manipulation (gene transfer/transduction)
82. PUVA treated
83. CD34 enriched (CD34+ selection)
84. CD133 enriched
85. Monocyte enriched
86. Mononuclear cells enriched
87. T-cell depletion
88.
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
Other cell manipulation
☐ Yes
☐ No
89.
Specify other cell manipulation:__________________________
Clinical Status of Recipient Prior to the Preparative Regimen (Conditioning)
90. What scale was used to determine the recipients functional status?
☐ Karnofsky (recipient age ≥ 16 years)
Performance score prior to the preparative regimen:
91. Karnofsky Scale (recipient age ≥ 16 years):
☐ 100 Normal; no complaints; no evidence of disease
☐ 90 Able to carry on normal activity
☐ 80 Normal activity with effort
☐ 70 Cares for self; unable to carry on normal activity or to do active work
☐ 60 Requires occasional assistance but is able to care for most needs
☐ 50 Requires considerable assistance and frequent medical care
☐ 40 Disabled; requires special care and assistance
☐ 30 Severely disabled; hospitalization indicated, although death not imminent
☐ 20 Very sick; hospitalization necessary
☐ 10 Moribund; fatal process progressing rapidly.
92.
Lansky Scale (recipient age < 16 years):
☐ Lansky (recipient age < 16 years)
☐ 100 Fully active
☐ 90 Minor restriction in physically strenuous play
☐ 80 Restricted in strenuous play, tires more easily, otherwise active
☐ 70 Both greater restrictions of, and less time spent in, active play
☐ 60 Ambulatory up to 50% of time, limited active play with assistance/supervision
☐ 50 Considerable assistance required for any active play; fully able to engage in
quiet play
☐ 40 Able to initiate quiet activities
☐ 30 Needs considerable assistance for quiet activity
☐ 20 Limited to very passive activity initiated by others (e.g., TV)
☐ 10 Completely disabled, not even passive play
CIBMTR Form 2400 revision 4 (page 6 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
93. Recipient CMV-antibodies (IgG or Total):
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ Reactive
☐ Non-reactive
☐ Not done
Co-morbid Conditions
☐ No
95. Is there a history of proven invasive fungal infection? ☐ Yes
☐ No
94. Is there a history of mechanical ventilation?
☐ Yes
96. Were there clinically significant co-existing diseases or organ impairment at time of patient assessment prior to preparative regimen?
Source: Blood, 2005 Oct 15;106(8):2912-2919
☐ Yes
☐ No
97. Arrhythmia - For example, any history of atrial fibrillation or flutter, sick sinus
syndrome, or ventricular arrhythmias requiring treatment
☐ Yes
98.
Cardiac - Any history of coronary artery disease (one or more vessel-coronary
artery stenosis requiring medical treatment, stent, or bypass graft), congestive
heart failure, myocardial infarction, OR ejection fraction ≤ 50% on the most
recent test
☐ Yes
☐ No ☐ Unknown
☐ No ☐ Unknown
99. Cerebrovascular disease - Any history of transient ischemic attack,
subarachnoid hemorrhage or cerebrovascular accident
☐ Yes
☐ No ☐ Unknown
100. Diabetes - Requiring treatment with insulin or oral hypoglycemics in the last 4
weeks but not diet alone
☐ Yes
☐ No ☐ Unknown
101. Heart valve disease - Except asymptomatic mitral valve prolapse
☐ Yes
☐ No ☐ Unknown
102. Hepatic, mild - Chronic hepatitis, bilirubin > upper limit of normal to 1.5 × upper
limit of normal, or AST/ALT > upper limit of normal to 2.5 × upper limit of normal
at the time of transplant OR any history of hepatitis B or hepatitis C infection
☐ Yes
☐ No ☐ Unknown
103. Hepatic, moderate/severe - Liver cirrhosis, bilirubin > 1.5 × upper limit of
normal, or AST/ALT > 2.5 × upper limit of normal
☐ Yes
☐ No ☐ Unknown
104. Infection - For example, documented infection, fever of unknown origin, or
pulmonary nodules requiring continuation of antimicrobial treatment after day 0
☐ Yes
☐ No ☐ Unknown
105. Inflammatory bowel disease - Any history of Crohn’s disease or ulcerative colitis
requiring treatment
☐ Yes
☐ No ☐ Unknown
106. Obesity - Patients with a body mass index > 35 kg/m2 at time of transplant
☐ Yes
☐ No ☐ Unknown
107. Peptic ulcer - Any history of peptic ulcer confirmed by endoscopy and
requiring treatment
☐ Yes
☐ No ☐ Unknown
108. Psychiatric disturbance - For example, depression, anxiety, bipolar disorder or
schizophrenia requiring psychiatric consult or treatment in the last 4 weeks
☐ Yes
☐ No ☐ Unknown
CIBMTR Form 2400 revision 4 (page 7 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
109. Pulmonary, moderate - Corrected diffusion capacity of carbon monoxide and/or
FEV1 66-80% or dyspnea on slight activity at transplant
☐ Yes
☐ No ☐ Unknown
110. Pulmonary, severe - Corrected diffusion capacity of carbon monoxide and/or
FEV1 ≤ 65% or dyspnea at rest or requiring oxygen at transplant
☐ Yes
☐ No ☐ Unknown
111. Renal, moderate/severe - Serum creatinine > 2 mg/dL or > 177 μmol/L or on
dialysis at transplant, OR prior renal transplantation
☐ Yes
☐ No ☐ Unknown
112. Rheumatologic - For example, any history of systemic lupus erythmatosis,
rheumatoid arthritis, polymyositis, mixed connective tissue disease, or
polymyalgia rheumatica requiring treatment (do NOT include degenerative joint
disease, osteoarthritis)
☐ Yes
☐ No ☐ Unknown
113. Solid tumor, prior - Treated at any time point in the patient’s past history,
excluding non-melanoma skin cancer, leukemia, lymphoma or multiple myeloma
☐ Yes 114. Breast cancer
☐ No ☐ Yes 115. Year of diagnosis: ___ ___ ___ ___
☐ Unknown
☐ No
116. Central nervous system (CNS) malignancy (glioblastoma,
astrocytoma)
☐ Yes
☐ No
117. Year of diagnosis: ___ ___ ___ ___
118. Gastrointestinal malignancy (colon, rectum, stomach, pancreas,
intestine)
☐ Yes
☐ No
119. Year of diagnosis: ___ ___ ___ ___
120. Genitourinary malignancy (kidney, bladder, ovary, testicle,
genitalia, uterus, cervix)
☐ Yes
☐ No
121. Year of diagnosis: ___ ___ ___ ___
122. Lung cancer
☐ Yes
☐ No
123. Year of diagnosis: ___ ___ ___ ___
124. Melanoma
☐ Yes
☐ No
125. Year of diagnosis: ___ ___ ___ ___
126. Oropharyngeal cancer (tongue, buccal mucosa)
☐ Yes
☐ No
127. Year of diagnosis: ___ ___ ___ ___
128. Sarcoma
CIBMTR Form 2400 revision 4 (page 8 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
☐ Yes
☐ No
129. Year of diagnosis: ___ ___ ___ ___
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
130. Thyroid cancer
☐ Yes
☐ No
131. Year of diagnosis: ___ ___ ___ ___
132. Other co-morbid condition
☐ Yes
133. Specify other co-morbid condition:________________________
☐ No
☐ Unknown
134. Was there a history of malignancy (hematologic or non-melanoma skin cancer) other than the primary disease for which this HCT is being
performed?
☐ Yes
☐ No
Specify which malignancy(ies) occurred:
135. Acute myeloid leukemia (AML/ANLL)
☐ Yes
☐ No
136. Year of diagnosis: ___ ___ ___ ___
137. Other leukemia, including ALL
☐ Yes
☐ No
138. Year of diagnosis: ___ ___ ___ ___
139. Specify leukemia: _____________________________________
140. Clonal cytogenetic abnormality without leukemia or MDS
☐ Yes
☐ No
141. Year of diagnosis: ___ ___ ___ ___
142. Hodgkin disease
☐ Yes
☐ No
143. Year of diagnosis: ___ ___ ___ ___
144. Lymphoma or lymphoproliferative disease
☐ Yes
☐ No
145. Year of diagnosis: ___ ___ ___ ___
146. Was the tumor EBV positive?
☐ Yes
☐ No
147. Other skin malignancy (basal cell, squamous)
☐ Yes
☐ No
148. Year of diagnosis: ___ ___ ___ ___
149. Specify other skin malignancy:___________________________
150. Myelodysplasia (MDS)/myeloproliferative (MPN) disorder
☐ Yes
☐ No
151. Year of diagnosis: ___ ___ ___ ___
152. Other prior malignancy
☐ Yes
☐ No
153. Year of diagnosis: ___ ___ ___ ___
154. Specify other prior malignancy:___________________________
Pre-HCT Preparative Regimen (Conditioning)
155. Height at initiation of pre-HCT preparative regimen: ___ ___ ___ ☐ inches
156. Actual weight at initiation of pre-HCT preparative regimen: ___ ___ ___
CIBMTR Form 2400 revision 4 (page 9 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
☐ centimeters
☐ pounds ☐ kilograms
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
157. Was a pre-HCT preparative regimen prescribed?
☐ Yes
☐ No
158. Classify the recipient’s prescribed preparative regimen:
☐ Myeloablative
☐ Non-myeloablative (NST)
☐ Reduced intensity (RIC)
159. Date pre-HCT preparative regimen began (irradiation or drugs):
__ __ __ __ / __ __ / __ __
YYYY
MM
DD
(Use earliest date from questions 163, or 168-315)
160. Was irradiation planned as part of the pre-HCT preparative regimen?
☐ Yes
☐ No
161. What was the prescribed radiation field?
☐ Total body
☐ Total body by tomotherapy
☐ Total lymphoid or nodal regions
☐ Thoracoabdominal region
162. Total prescribed dose: (dose per fraction x total number of
fractions)
___ ___ ___ ___
☐ Gy
☐ cGy
163. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
164. Was the radiation fractionated?
☐ Yes
165. Prescribed dose per fraction:
167. Total number of fractions: ___ ___
☐ No
___ ___ ___ ☐ Gy
☐ cGy
166. Number of days: (include “rest” days) ___
Indicate the total prescribed cumulative dose for the preparative regimen:
168. ALG, ALS, ATG, ATS
☐ Yes 169. Total prescribed dose ___ ___ ___ ___ ☐ mg/m
☐ No
2
☐ mg/kg
170. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
171. Specify source:
☐ Horse
☐ Rabbit
` ☐ Other source
172. Specify other source:
_____________________________
173. Anthracycline
☐ Yes 174. Daunorubicin
☐ No
☐ Yes
175.
☐ No
CIBMTR Form 2400 revision 4 (page 10 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
Total prescribed dose:
___ ___ ___ ___
☐ mg/m
2
☐ mg/kg
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
176. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
177. Doxorubicin (Adriamycin)
☐ Yes 178. Total prescribed dose:
☐ No ___ ___ ___ ___ ☐ mg/m ☐ mg/kg
2
179. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
180. Idarubicin
☐ Yes 181.
☐ No
Total prescribed dose:
___ ___ ___ ___ ☐ mg/m2
☐ mg/kg
182. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
183. Rubidazone
☐ Yes
184.
☐ No
Total prescribed dose:
___ ___ ___ ___
☐ mg/m
2
☐ mg/kg
185. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
186. Other anthracycline
☐ Yes
187. Total prescribed dose:
☐ No
___ ___ ___ ___
☐ mg/m
2
☐ mg/kg
188. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
189. Specify other anthracycline:____________
__________________________________
190. Bleomycin (BLM, Blenoxane)
☐ Yes 191. Total prescribed dose: ___ ___ ___ ___ ☐ mg/m ☐ mg/kg
☐ No
2
192. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
193. Busulfan (Myleran)
☐ Yes 194. Total prescribed dose: ___ ___ ___ ___
☐ No
☐ mg/m ☐ mg/kg ☐ Target total AUC (µmol x min/L)
2
195. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
196. Specify administration: ☐ Oral
☐ IV
☐ Both
197. Carboplatin
☐ Yes 198. Total prescribed dose: ___ ___ ___ ___ ☐ mg/m
☐ No
2
199. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
CIBMTR Form 2400 revision 4 (page 11 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
☐ mg/kg
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
200. Were pharmacokinetics performed to determine preparative
regimen drug dosing?
☐ Yes
☐ No
201. Specify the target AUC:
___ ___ ___ mg/mL/minute
202. Cisplatin (Platinol, CDDP)
☐ Yes
203. Total prescribed dose: ___ ___ ___ ___ ☐ mg/m
☐ No
2
☐ mg/kg
204. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
205. Cladribine (2-CdA, Leustatin)
☐ Yes
☐ No
206. Total prescribed dose: ___ ___ ___ ___ ☐ mg/m2
☐ mg/kg
207. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
208. Corticosteroids (excluding anti-nausea medication)
☐ Yes
☐ No
209. Methylprednisolone (Solu-Medrol)
☐ Yes
210.
☐ No
Total prescribed dose:
___ ___ ___ ___
☐ mg/m
2
☐ mg/kg
211. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
212. Prednisone
☐ Yes 213.
☐ No
Total prescribed dose:
___ ___ ___ ___
☐ mg/m
2
☐ mg/kg
214. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
215. Dexamethasone
☐ Yes
216.
☐ No
Total prescribed dose:
___ ___ ___ ___ ☐ mg/m2 ☐ mg/kg
217. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
218. Other corticosteroid
☐ Yes
219. Total prescribed dose:
☐ No
___ ___ ___ ___ ☐ mg/m2
☐ mg/kg
220. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
221. Specify other corticosteroid:
__________________________________
222. Cyclophosphamide (Cytoxan)
☐ Yes
223.
☐ No
Total prescribed dose: ___ ___ ___ ___ ☐ mg/m2
224. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
CIBMTR Form 2400 revision 4 (page 12 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
☐ mg/kg
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
225. Cytarabine (Ara-C)
☐ Yes
☐ No
226. Total prescribed dose: ___ ___ ___ ___
☐ mg/m ☐ mg/kg
2
227. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
228. Etoposide (VP-16, VePesid)
☐ Yes 229.
☐ No
2
☐ mg/kg
231. Fludarabine
☐ Yes
232. Total prescribed dose: ___ ___ ___ ___ ☐ mg/m
☐ No
☐ mg/kg
Total prescribed dose: ___ ___ ___ ___
☐ mg/m
230. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
2
233. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
234. Ifosfamide
☐ Yes
☐ No
235. Total prescribed dose: ___ ___ ___ ___
☐ mg/m
2
☐ mg/kg
236. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
237. Intrathecal therapy (chemotherapy)
☐ Yes
238. Intrathecal cytarabine (IT Ara-C)
☐ No ☐ Yes 239. Total prescribed dose:
☐ No
___ ___ ___ ___ ☐ mg/m ☐ mg/kg
2
240. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
241. Intrathecal methotrexate (IT MTX)
☐ Yes
242. Total prescribed dose:
☐ Yes
245. Total prescribed dose:
☐ No
___ ___ ___ ___ ☐ mg/m2
☐ mg/kg
243. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
244. Intrathecal thiotepa
☐ No
___ ___ ___ ___ ☐ mg/m2
☐ mg/kg
246. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
247. Other intrathecal drug
☐ Yes
☐ No
CIBMTR Form 2400 revision 4 (page 13 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
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248. Total prescribed dose:
___ ___ ___ ___
☐ mg/m
2
☐ mg/kg
249. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
250. Specify other intrathecal drug:
__________________________________
251. Melphalan (L-Pam)
☐ Yes
252.
☐ No
Total prescribed dose: ___ ___ ___ ___
☐ mg/m
☐ mg/kg
2
253. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
254. Specify administration: ☐ Oral
☐ IV
☐ Both
255. Mitoxantrone
☐ Yes
☐ No
256. Total prescribed dose: ___ ___ ___ ___ ☐ mg/m2
☐ mg/kg
257. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
258. Monoclonal antibody
☐ Yes
259. Radio labeled mAb
☐ No ☐ Yes
260.
☐ No
Total prescribed dose of radioactive
component: ___ ___ ___ ___ ● ___
☐ mCi
☐ MBq
261. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
Specify radio labeled mAb:
☐ Yes ☐ No
262. Tositumomab (Bexxar)
263. Ibritumomab tiuxetan (Zevalin)
264. Other radio labeled mAb
☐ Yes
☐ No
☐ Yes 265. Specify radio labeled
☐ No mAb:
266. Alemtuzumab (Campath)
__________________
☐ Yes
267. Total prescribed dose:
☐ No ___ ___ ___ ___ ☐ mg/m2 ☐ mg/kg
268. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
269. Rituximab (Rituxan, anti CD20)
☐ Yes
270. Total prescribed dose: ___ ___ ___ ___
☐ No ☐ mg/m2 ☐ mg/kg
271. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
272. Gemtuzumab (Mylotarg, anti CD33)
☐ Yes
273. Total prescribed dose:
☐ No
CIBMTR Form 2400 revision 4 (page 14 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
___ ___ ___ ___ ☐ mg/m2
☐ mg/kg
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
274. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
275. Other mAb
☐ Yes
276. Total prescribed dose:
☐ No
___ ___ ___ ___ ☐ mg/m2
☐ mg/kg
277. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
278. Specify other mAb:____________________
279. Nitrosourea
☐ Yes
☐ No
280. Carmustine (BCNU)
☐ Yes
281. Total prescribed dose: ___ ___ ___ ___
☐ No
☐ mg/m2 ☐ mg/kg
282. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
283. CCNU (Lomustine)
☐ Yes
☐ No
284. Total prescribed dose: ___ ___ ___ ___
☐ mg/m2 ☐ mg/kg
285. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
286. Other nitrosourea
☐ Yes
☐ No
287. Total prescribed dose: ___ ___ ___ ___
289. Specify other nitrosourea:
☐ mg/m2 ☐ mg/kg
288. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
___________________________________
290. Paclitaxel (Taxol, Xyotax)
☐ Yes
☐ No
291. Total prescribed dose: ___ ___ ___ ___ ☐ mg/m2
☐ mg/kg
292. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
293. Teniposide (VM26)
☐ Yes
☐ No
294. Total prescribed dose: ___ ___ ___ ___ ☐ mg/m2
☐ mg/kg
295. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
296. Thiotepa
☐ Yes
☐ No
297. Total prescribed dose: ___ ___ ___ ___ ☐ mg/m2
298. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
CIBMTR Form 2400 revision 4 (page 15 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
☐ mg/kg
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
299. Treosulfan
☐ Yes
300. Total prescribed dose: ___ ___ ___ ___ ___
☐ No
☐ mg/m ☐ mg/kg
2
301. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
302. Tyrosine kinase inhibitors
☐ Yes
☐ No
303. Dasatinib (Sprycel)
☐ Yes
304. Total prescribed dose: ___ ___ ___ ___
☐ No
☐ mg/m2 ☐ mg/kg
305. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
306. Imatinib mesylate (STI571, Gleevec)
☐ Yes
☐ No
307. Total prescribed dose: ___ ___ ___ ___
☐ mg/m2 ☐ mg/kg
308. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
309. Nilotinib
☐ Yes
☐ No
310. Total prescribed dose: ___ ___ ___ ___
☐ mg/m2 ☐ mg/kg
311. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
312. Other drug
☐ Yes
313. Total prescribed dose: ___ ___ ___ ___ ___
☐ No
☐ mg/m ☐ mg/kg
2
314. Date started: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
315. Specify other drug:_____________________________________
GVHD Prophylaxis
This section is to be completed for allogeneic HCTs only; autologous HCTs continue with question 342.
316. Was GVHD prophylaxis planned/given?
☐ Yes
☐ No
Specify:
317. ALG, ALS, ATG, ATS
☐ Yes
☐ No
318. Specify source:
☐ Horse
☐ Rabbit
☐ Other source
319. Specify other source:
_____________________________
320. Corticosteroids (systemic)
321. Cyclosporine (CSA, Neoral, Sandimmune)
CIBMTR Form 2400 revision 4 (page 16 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
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☐ Yes
☐ Yes
☐ No
☐ No
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
322. Cyclophosphamide (Cytoxan)
323. Extra-corporeal photopheresis (ECP)
324. FK 506 (Tacrolimus, Prograf)
☐ Yes
☐ Yes
☐ Yes
☐ No
☐ No
☐ No
325. In vivo monoclonal antibody
☐ Yes
☐ No
Specify in vivo monoclonal antibody:
326. Alemtuzumab (Campath)
☐ Yes
☐ No
327. Anti CD 25 (Zenapax, Daclizumab, AntiTAC)
☐ Yes
☐ No
328. Specify: _____________________________
329. Etanercept (Enbrel)
330. Infliximab (Remicade)
☐ Yes
☐ Yes
☐ No
☐ No
331. Other in vivo monoclonal antibody
☐ Yes 332. Specify antibody: _____________________
☐ No
___________________________________
333. In vivo immunotoxin
☐ Yes
☐ No
334. Specify immunotoxin:___________________________________
335. Methotrexate (MTX) (Amethopterin)
336. Mycophenolate mofetil (MMF) (CellCept)
337. Sirolimus (Rapamycin, Rapamune)
☐ Yes
☐ Yes
☐ Yes
☐ No
☐ No
☐ No
338. Blinded randomized trial
☐ Yes
☐ No
339. Specify trial agent:______________________________________
340. Other agent
☐ Yes
☐ No
341. Specify other agent:____________________________________
Other Toxicity Modifying Regimen
Optional for non-U.S. Centers
342. Was KGF (palifermin, Kepivance) started or is there a plan to use it? ☐ Yes
☐ No
☐ Masked trial
Post-HCT Disease Therapy Planned as of Day 0
343. Is this HCT part of a planned multiple (sequential) graft/HCT protocol?
☐ Yes ☐ No
344. Is additional post-HCT therapy planned?
☐ Yes
☐ No
Questions 345 – 355 are optional for non-U.S. centers
345. Bortezomib (Velcade)
346. Cellular therapy (e.g. DCI, DLI)
347. Dexamethosone
CIBMTR Form 2400 revision 4 (page 17 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
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☐ Yes
☐ Yes
☐ Yes
☐ No
☐ No
☐ No
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
348. Intrathecal therapy (chemotherapy)
349. Tyrosine kinase inhibitor (e.g. imatinib mesylate)
350. Lenalidomide (Revlimid)
351. Local radiotherapy
352. Rituximab (Rituxan, Mabthera)
353. Thalidomide (Thalomid)
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
354. Other therapy
☐ Yes
☐ No
355. Specify other therapy:___________________________________
Primary Disease for HCT
356. Date of diagnosis of primary disease for HCT: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
357. What was the primary disease for which the HCT was performed?
☐ Acute myelogenous leukemia(AML or ANLL) (10)
Acute Myelogenous Leukemia (AML)
358. Specify the AML classification:
☐ AML with t(9;11) (p22;q23); MLLT 3-MLL (5)
☐ AML with t(6;9) (p23;q24); DEK-NUP214 (6)
☐ AML with inv(3) (q21;q26.2) or t(3;3) (q21;q26.2); RPN1-EVI1 (7)
☐ AML (megakaryoblastic) with t(1;22) (p13;q13); RBM15-MKL1 (8)
☐ AML with t(8;21); (q22; q22); RUNX1/RUNX1T1 (281)
☐ AML with inv(16); (p13;1q22) or t(16;16) (p13.1; q22); CBFB/MYH11(282)
☐ APL with t(15;17); (q22;q12); RARA;PML (283)
☐ AML with 11q23 (MLL) abnormalities (i.e., t(4;11), t(6;11), t(9;11), t(11;19)) (284)
☐ AML with myelodysplasia – related changes (285)
☐ Therapy related AML (t-AML) (9)
☐ Myeloid sarcoma (295)
☐ Blastic plasmacytoid dendritic cell neoplasm (296)
☐ AML or ANLL, not otherwise specified (280)
☐ AML, minimally differentiated (M0) (286)
☐ AML without maturation (M1) (287)
☐ AML with maturation (M2) (288)
☐ Acute myelomonocytic leukemia (M4) (289)
☐ Acute monoblastic/acute monocytic leukemia (M5) (290)
☐ Acute erythroid leukemia (erythroid/myeloid and pure erythroleukemia) (M6) (291)
☐ Acute megakaryoblastic leukemia (M7) (292)
☐ Acute basophilic leukemia (293)
☐ Acute panmyelosis with myelofibrosis (294)
CIBMTR Form 2400 revision 4 (page 18 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
359. Did AML transform from MDS or MPN?
☐ Yes - Also complete Disease Classification questions 480-527
☐ No
360. Is the disease (AML) therapy related?
☐ Yes ☐ No ☐ Unknown
361. Did the recipient have a predisposing condition?
☐ Yes
362. Specify condition:
☐ No ☐ Bloom syndrome
☐ Unknown
☐ Down syndrome
☐ Fanconi anemia
☐ Neurofibromatosis type 1
☐ Other condition 363. Specify other condition:
___________________________
364. Were cytogenetics tested (conventional or FISH)?
☐ Yes
365. Results of tests:
☐ No ☐ Abnormalities identified
☐ Unknown ☐ No evaluable metaphases
☐ No abnormalities
Specify cytogenetic abnormalities identified at
any time prior to the start of the preparative
regimen:
Monosomy
366. –5
367. –7
368. –17
369. –18
370. –X
371. –Y
Trisomy
372. +4
373. +8
374. +11
375. +13
376. +14
377. +21
378. +22
Translocation
379. t(3;3)
380. t(6;9)
381. t(8;21)
382. t(9;11)
383. t(9;22)
384. t(15;17) and variants
CIBMTR Form 2400 revision 4 (page 19 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ Yes
☐ No
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
☐ Yes
☐ Yes
☐ No
☐ No
397. (11q23) any ☐ Yes
abnormality
☐ No
385. t(16;16)
Deletion
386. del(3q)/3q–
387. del(5q)/5q–
388. del(7q)/7q–
389. del(9q)/9q–
390. del(11q)/11q–
391. del(16q)/16q–
392. del(17q)/17q–
393. del(20q)/20q–
394. del(21q)/21q–
Inversion
395. inv(3)
396. inv(16)
Other
398. 12p any abnormality
400. Other abnormality
☐ Yes
399. Complex - ≥ 3 distinct ☐ Yes
abnormalities
☐ Yes
☐ No
☐ No
☐ No
401. Specify other
abnormality:
____________________
402. Were tests for molecular markers performed (e.g. PCR)?
☐ Yes
☐ No
☐ Unknown
Specify molecular markers identified at any time prior to the
start of the preparative regimen:
403. CEBPA
☐ Positive ☐ Negative
404. FLT3 – D835 point mutation
☐ Positive ☐ Negative
405. FLT3 – ITD mutation
406. IDH1
☐ Positive ☐ Negative
☐ Not done
☐ Not done
☐ Not done
407. IDH2
☐ Positive ☐ Negative
☐ Not done
☐ Positive ☐ Negative
☐ Not done
408. KIT
☐ Positive ☐ Negative ☐ Not done
409. NPM1
☐ Positive
CIBMTR Form 2400 revision 4 (page 20 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
☐ Negative
☐ Not done
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
410. Other molecular marker
☐ Positive
411. Specify other molecular marker:
☐ Negative
___________________________
☐ Not done
Status at transplantation
412. What was the disease status (based on hematologic test results)?
☐ Primary induction failure (PIF)
☐ 1st complete remission
(no previous bone marrow or
extramedullary relapse)
☐ 2nd complete remission
☐ ≥ 3rd complete remission
413. How many cycles of induction
therapy were required to achieve
CR?
☐ 1 ☐ 2 ☐ ≥ 3
414. Was the recipient in molecular
remission?
☐ Yes
☐ No
☐ Unknown
☐ Not applicable
415. Was the recipient in remission by
flow cytometry?
☐ Yes
☐ No
☐ Unknown
☐ Not applicable
416. Was the recipient in cytogenetic
remission?
☐ Yes
☐ No
☐ Unknown
☐ Not applicable
☐ 1st relapse
☐ 2nd relapse
☐ ≥ 3rd relapse
☐ No treatment
417. Date of most recent relapse:
__ __ __ __ / __ __ / __ __
YYYY
MM
DD
418. Date assessed: __ __ __ __ / __ __ / __ __ - Go to First Name
YYYY
MM
DD
CIBMTR Form 2400 revision 4 (page 21 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ Acute lymphoblastic leukemia (ALL) (20)
Acute Lymphoblastic Leukemia (ALL)
419. Specify ALL classification:
☐ t(9;22)(q34;q11); BCR/ABL1 (192)
☐ t(v;11q23); MLL rearranged (193)
☐ t(1;19)(q23;p13) TCF3-PBX1 (194)
☐ t(12;21) (p12;q22); TEL-AML1 (195)
☐ t(5;14) (q31;q32); IL3-IGH (81)
☐ Hyperdiploidy (51-65 chromosomes) (82)
☐ Hypodiploidy (<45 chromosomes) (83)
☐ B-cell ALL, NOS {L1/L2} (191)
☐ T-cell lymphoblastic leukemia/lymphoma (Precursor T-cell ALL) (196)
☐ ALL, NOS (190)
420. Were tyrosine kinase inhibitors (i.e.imatinib mesylate) given for pre-HCT
therapy at any time prior to start of the preparative regimen?
☐ Yes
☐ No
421. Were cytogenetics tested (conventional or FISH)?
☐ Yes
422. Results of tests:
☐ No
☐ Abnormalities identified
☐ Unknown
☐ No evaluable metaphases
☐ No abnormalities
Specify cytogenetic abnormalities identified at
any time prior to the start of the preparative
regimen:
Monosomy
423. –7
Trisomy
424. +4
425. +8
426. +17
427. +21
Translocation
428. t(1;19)
429. t(2;8)
430. t(4;11)
431. t(5;14)
432. t(8;14)
433. t(8;22)
434. t(9;22)
435. t(10;14)
436. t(11;14)
437. t(12;21)
CIBMTR Form 2400 revision 4 (page 22 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
☐ Yes
☐ No
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ No
☐ No
☐ No
☐ No
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Deletion
438. del(6q)/6q–
439. del(9p)/9p–
440. del(12p)/12p–
Addition
441. add(14q)
Other
☐ Yes
☐ Yes
☐ Yes
☐ No
☐ No
☐ No
☐ Yes
☐ No
442. (11q23) any
☐ Yes ☐ No
abnormality
☐ Yes
444. 12p any abnormality ☐ Yes
445. Hyperdiploid (> 50) ☐ Yes
446. Hypodiploid (< 46) ☐ Yes
447. Complex - ≥ 3 distinct ☐ Yes
443. 9p any abnormality
abnormalities
448. Other abnormality
☐ No
☐ No
☐ No
☐ No
☐ No
☐ Yes
449. Specify other
☐ No abnormality:
450. Were tests for molecular markers performed (e.g. PCR)?
☐ Yes
☐ No
☐ Unknown
Specify molecular markers identified at any time prior to
the start of the preparative regimen:
451. BCR/ABL
☐ Positive ☐ Negative
452. TEL-AML/AML1
☐ Positive
____________________
☐ Negative
☐ Not done
☐ Not done
453. Other molecular marker
☐ Positive
☐ Negative
454. Specify other molecular marker:
☐ Not done
___________________________
Status at Transplantation:
455. What was the disease status (based on hematologic test results)?
☐ Primary induction failure
☐ 1st complete remission
(no previous bone marrow or
extramedullary relapse)
☐ 2nd complete remission
☐ ≥ 3rd complete remission
456. How many cycles of induction
therapy were required to achieve
CR?
☐ 1 ☐ 2 ☐ ≥ 3
457. Was the recipient in molecular
remission?
☐ Yes
☐ No
☐ Unknown
CIBMTR Form 2400 revision 4 (page 23 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ Not applicable
458. Was the recipient in remission by
flow cytometry?
☐ Yes
☐ No
☐ Unknown
☐ Not applicable
459. Was the recipient in cytogenetic
remission?
☐ Yes
☐ No
☐ Unknown
☐ Not applicable
☐ 1st relapse
☐ 2nd relapse
☐ ≥ 3rd relapse
☐ No treatment
460. Date of most recent relapse:
__ __ __ __ / __ __ / __ __
YYYY
MM
DD
461. Date assessed: __ __ __ __ / __ __ / __ __ - Go to First Name
YYYY
MM
DD
☐ Other acute leukemia (80)
Other Acute Leukemia
462. Specify other acute leukemia classification:
☐ Acute undifferentiated leukemia (31)
☐ Biphenotypic, bilineage or hybrid leukemia (32)
☐ Acute mast cell leukemia (33)
☐ Other acute leukemia (89)
463. Specify other acute leukemia:
______________________________
Status at Transplantation:
464. What was the disease status (based on hematologic test results)?
☐ Primary induction failure
☐ 1st complete remission (no previous marrow or extramedullary relapse)
☐ 2nd complete remission
☐ ≥ 3rd complete remission
☐ 1st relapse
☐ 2nd relapse
☐ ≥ 3rd relapse
☐ No treatment
465. Date assessed: __ __ __ __ / __ __ / __ __ - Go to First Name
YYYY
MM
DD
CIBMTR Form 2400 revision 4 (page 24 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
☐ Chronic myelogenous leukemia
(CML) (40)
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Chronic Myelogenous Leukemia (CML) Philadelphia chromosome+, Ph+, t(9;22)
(q34;q11), or variant OR bcr/abl+
466. Specify CML classification:
☐ Ph+/bcr+ (41)
☐ Ph+/bcr- (42)
☐ Ph+/bcr unknown (43)
☐ Ph-/bcr+ (44)
☐ Ph unknown/bcr+ (47)
467. Was therapy given prior to this HCT?
☐ Yes
☐ Yes
☐ Yes
☐ No
☐ No
☐ No
471. Interferon-α (Intron, Roferon) (includes
☐ Yes
PEG)
☐ No
☐ Yes
☐ No
468. Combination chemotherapy
469. Hydroxyurea (HU)
470. Tyrosine kinase inhibitor (e.g.imatinib
mesylate, dasatinib, nilotinib)
472. Other therapy
☐ Yes
473. Specify other therapy:
☐ No ______________________________
474. What was the disease status at last evaluation prior to the start of the preparative
regimen?
☐ Complete hematologic remission
☐ First chronic phase
Specify remission:
475. Cytogenetic complete remission
(Ph negative)
☐ Yes
☐ No
☐ Unknown
476. Molecular complete remission
(BCR/ABL negative)
☐ Yes
☐ No
☐ Unknown
477. CML disease status before
treatment that achieved this CR:
☐ Chronic phase
☐ Accelerated phase
☐ Blast phase
☐ Second or greater chronic phase
☐ Accelerated phase
☐ Blast crisis
- Go to question 478
478. Number
☐ 1st
☐ 2nd
☐ 3rd or higher
479. Date assessed: __ __ __ __ / __ __ / __ __ - Go to First Name
YYYY
MM
DD
CIBMTR Form 2400 revision 4 (page 25 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ Myelodysplastic (MDS) / myeloproliferative (MPN) diseases (50) (Please classify all pre-leukemias) (If recipient has transformed to AML,
indicate AML as the primary disease)
Myelodysplastic (MDS)/Myeloproliferative (MPN) Diseases
480. What was the MDS/MPN classification at diagnosis? - If transformed to AML,
indicate AML as primary disease; also complete Disease Classification
questions 358-418
☐ Refractory cytopenia with unilineage dysplasia (RCUD) (includes refractory anemia
(RA)) (51)
☐ Refractory anemia with ringed sideroblasts (RARS) (55)
☐ Refractory anemia with excess blasts-1 (RAEB-1) (61)
☐ Refractory anemia with excess blasts-2 (RAEB-2) (62)
☐ Refractory cytopenia with multilineage dysplasia (RCMD) (64)
☐ Childhood myelodysplastic syndrome (Refractory cytopenia of childhood (RCC))
(68)
☐ Myelodysplastic syndrome with isolated del(5q) (5q– syndrome) (66)
☐ Myelodysplastic syndrome (MDS), unclassifiable (50)
☐ Chronic neutrophilic leukemia (165)
☐ Chronic eosinophilic leukemia, NOS (166)
☐ Essential thrombocythemia (includes primary thrombocytosis, idiopathic
thrombocytosis, hemorrhagic thrombocythemia) (58)
myeloid metaplasia (AMM), myelofibrosis/sclerosis with myeloid metaplasia
(MMM), idiopathic myelofibrosis) (167)
☐ Polycythemia vera (PCV) (57)
☐ Primary myelofibrosis (includes chronic idiopathic myelofibrosis (CIMF), angiogenic
☐ Myeloproliferative neoplasm (MPN), unclassifiable (60)
☐ Chronic myelomonocytic leukemia (CMMoL) (54)
☐ Juvenile myelomonocytic leukemia (JMML/JCML) (no evidence of Ph
1
BCR/ABL) (36) - Go to question 525
or
☐ Atypical chronic myeloid leukemia, Ph-/bcr/abl- {CML, NOS} (45)
- Go to question 577
☐ Atypical chronic myeloid leukemia, Ph-/bcr unknown {CML, NOS} (46)
- Go to question 577
☐ Atypical chronic myeloid leukemia, Ph unknown/bcr- {CML, NOS} (48)
- Go to question 577
☐ Atypical chronic myeloid leukemia, Ph unknown/bcr unknown {CML,
NOS} (49) - Go to question 577
☐ Myelodysplastic/myeloproliferative neoplasm, unclassifiable (69)
481. Was the disease (MDS/MPN) therapy related?
☐ Yes
☐ No
☐ Unknown
482. Did the recipient have a predisposing condition?
☐ Yes
483. Specify condition:
☐ No
☐ Aplastic anemia
☐ Unknown ☐ Bloom syndrome
☐ Down syndrome
☐ Fanconi anemia
☐ Other condition
CIBMTR Form 2400 revision 4 (page 26 of 45). Last Updated October, 2013..
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
484. Specify other condition:
______________________________
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Laboratory Studies at Diagnosis of MDS
485. WBC
☐ Known 486. ___ ___ ___ ___ ___ ___ ● ___
☐ Unknown ☐ x 10 /L (x 10 /mm ) ☐ x 10 /L
9
3
3
6
487. Hemoglobin
☐ Known 488. ___ ___ ___ ___ ● ___ ___ ☐ g/dL
☐ Unknown
☐ g/L
☐ mmol/L
489. Was RBC transfused < 30 days before date of test?
☐ Yes
☐ No
490. Platelets
☐ Known 491. ___ ___ ___ ___ ___ ___ ___
☐ Unknown ☐ x 10 /L (x 10 /mm ) ☐ x 10 /L
9
3
3
6
492. Were platelets transfused < 7 days before date of test?
☐ Yes
☐ No
493. Neutrophils
☐ Known
☐ Unknown
494. ___ ___%
495. Blasts in bone marrow
☐ Known 496. ___ ___ ___ %
☐ Unknown
497. Were cytogenetics tested (conventional or FISH)?
☐ Yes
498. Results of tests:
☐ No
☐ Abnormalities identified
☐ Unknown
☐ No evaluable metaphases
☐ No abnormalities
Specify abnormalities identified at diagnosis:
499. Specify number of distinct cytogenetic
abnormalities:
☐ One (1)
☐ Two (2)
☐ Three (3)
☐ Four or more (4 or more)
Monosomy
500. –5
501. –7
502. –13
503. –20
504. –Y
Trisomy
505. +8
506. +19
CIBMTR Form 2400 revision 4 (page 27 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ No
☐ No
☐ No
☐ No
☐ No
☐ Yes
☐ Yes
☐ No
☐ No
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Translocation
507. t(1;3)
508. t(2;11)
509. t(3;3)
510. t(3;21)
511. t(6;9)
512. t(11;16)
Deletion
513. del(3q)/3q-
514. del(5q)/5q-
515. del(7q)/7q-
516. del(9q)/9q-
517. del(11q)/11q-
518. del(12p)/12p-
519. del(13q)/13q-
520. del(20q)/20q-
Inversion
521. inv(3)
Other
522. i17q
523. Other abnormality
☐ Yes
☐ No
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
☐ Yes
☐ No
☐ Yes
☐ No
524. Specify other abnormality:
____________________
525. Did the recipient progress or transform to a different MDS/MPN subtype between
diagnosis and the start of the preparative regimen?
☐ Yes
526.
☐ No
Specify the date of the most recent transformation:
__ __ __ __ / __ __ / __ __
YYYY
MM
DD
527. Specify the MDS/MPN classification after transformation:
☐ Refractory cytopenia with unilineage dysplasia (RCUD)
(includes refractory anemia (RA)) (51)
☐ Refractory anemia with ringed sideroblasts (RARS) (55)
☐ Refractory anemia with excess blasts-1 (RAEB-1) (61)
☐ Refractory anemia with excess blasts-2 (RAEB-2) (62)
☐ Refractory cytopenia with multilineage dysplasia (RCMD) (64)
☐ Childhood myelodysplastic syndrome (Refractory cytopenia of
childhood (RCC)) (68)
☐ Myelodysplastic syndrome with isolated del(5q)
(5q– syndrome) (66)
☐ Myelodysplastic syndrome (MDS), unclassifiable (50)
☐ Chronic neutrophilic leukemia (165)
☐ Chronic eosinophilic leukemia, NOS (166)
☐ Essential thrombocythemia (includes primary thrombocytosis,
CIBMTR Form 2400 revision 4 (page 28 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
idiopathic thrombocytosis, hemorrhagic thrombocythemia) (58)
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ Polycythemia vera (PCV) (57)
☐ Myeloproliferative neoplasm (MPN), unclassifiable (60)
☐ Chronic myelomonocytic leukemia (CMMoL) (54)
☐ Myelodysplastic/myeloproliferative neoplasm, unclassifiable
☐ Primary myelofibrosis (includes chronic idiopathic
myelofibrosis (CIMF), angiogenic myeloid metaplasia (AMM),
myelofibrosis/sclerosis with myeloid metaplasia (MMM),
idiopathic myelofibrosis) (167)
(69)
☐ Transformed to AML (70) - Go to First Name.
Laboratory studies at last evaluation prior to the start of the preparative regimen:
528. WBC
☐ Known 529. ___ ___ ___ ___ ___ ___ ● ___
☐ Unknown ☐ x 10 /L (x 10 /mm ) ☐ x 10 /L
9
3
3
6
530. Hemoglobin
☐ Known
☐ Unknown
531. ___ ___ ___ ___ ● ___ ___
☐ g/dL
☐ g/L
☐ mmol/L
532. Was RBC transfused < 30 days before date of test?
☐ Yes
☐ No
533. Platelets
☐ Known 534. ___ ___ ___ ___ ___ ___ ___
☐ Unknown ☐ x 10 /L (x 10 /mm ) ☐ x 10 /L
9
3
3
6
535. Were platelets transfused < 7 days before date of test?
☐ Yes
☐ No
536. Neutrophils
☐ Known
537. ___ ___%
☐ Known
☐ Unknown
539. ___ ___ ___ %
☐ Unknown
538. Blasts in bone marrow
540. Were cytogenetics tested (conventional or FISH)?
☐ Yes
541. Results of tests:
☐ No
☐ Abnormalities identified
☐ Unknown
☐ No evaluable metaphases
☐ No abnormalities
Specify cytogenetic abnormalities identified at
last evaluation prior to the start of the
preparative regimen:
542. Specify number of distinct cytogenetic
abnormalities:
☐ One (1)
☐ Two (2)
☐ Three (3)
☐ Four or more (4 or more)
CIBMTR Form 2400 revision 4 (page 29 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Monosomy
543. –5
544. –7
545. –13
546. –20
547. –Y
548. +8
549. +19
Translocation
550. t(1;3)
551. t(2;11)
552. t(3;3)
553. t(3;21)
554. t(6;9)
555. t(11;16)
Deletion
556. del(3q)/3q-
557. del(5q)/5q-
558. del(7q)/7q-
559. del(9q)/9q-
Trisomy
560. del(11q)/11q-
561. del(12p)/12p-
562. del(13q)/13q-
563. del(20q)/20q-
Inversion
564. inv(3)
Other
565. i17q
566. Other abnormality
☐ Yes
☐ No
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ No
☐ No
☐ No
☐ No
☐ No
☐ Yes
☐ Yes
☐ No
☐ No
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
☐ Yes
☐ No
☐ Yes
☐ No
567. Specify other abnormality:
____________________
Status at Transplantation
568. What was the disease status?
☐ Complete remission (CR) - requires all of the following, maintained for ≥ 4
weeks: * bone marrow evaluation: < 5% myeloblasts with normal maturation
of all cell lines * peripheral blood evaluation: hemoglobin ≥ 11 g/dL
untransfused and without erythropoietin support; ANC ≥ 1000/mm3 without
myeloid growth factor support; platlets ≥ 100 x 109/L without thrombopoietic
support; 0% blasts - Go to question 572
☐ Hematologic improvement (HI) - requires one measurement of the following,
maintained for ≥ 8 weeks without ongoing cytotoxic therapy; specify which
cell line was measured to determine HI response: * HI-E – hemoglobin
increase of ≥ 1.5 g/dL untransfused; for RBC transfusions performed for Hgb
≤ 9.0, reduction in RBC units transfused in 8 weeks by ≥ 4 units compared to
CIBMTR Form 2400 revision 4 (page 30 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
the pre-treatment transfusion number in 8 weeks * HI-P – for pre- treatment
platelet count of > 20 x 109/L, platelet absolute increase of ≥ 30 x 109/L; for
pre-treatment platelet count of < 20 x 109/L, platelet absolute increase of ≥ 20
x 109/L and ≥ 100% from pre-treatment level * HI-N – neutrophil count
increase of ≥ 100% from pre-treatment level and an absolute increase of ≥
500/mm3 - Go to question 569
☐ No response (NR)/stable disease (SD) - does not meet the criteria for at least
☐
HI, but no evidence of disease progression - Go to question 572
Progression from hematologic improvement (Prog from HI) – requires at least one
of the following, in the absence of another explanation (e.g., infection,
bleeding, ongoing chemotherapy, etc.): * ≥ 50% reduction from maximum
response levels in granulocytes or platelets * reduction in hemoglobin by ≥
1.5 g/dL *transfusion dependence - Go to question 570
☐ Relapse from complete remission (Rel from CR) - requires at least one of the
following: * return to pre-treatment bone marrow blast percentage * decrease
of ≥ 50% from maximum response levels in granulocytes or platelets *
transfusion dependence, or hemoglobin level ≥ 1.5 g/dL lower than prior to
therapy - Go to question 571
☐ Not assessed - Go to First Name.
569. Specify the cell line examined to determine HI status:
☐ HI-E - hemoglobin increase of ≥ 1.5 g/dL untransfused;
☐
for RBC transfusions performed for Hgb ≤ 9.0,
reduction in RBC units transfused in 8 weeks by ≥ 4
units compared to the pre-treatment transfusion number
in 8 weeks - Go to question 572
HI-P - for pre-treatment platelet count of > 20 x 10 9L,
platelet absolute increase of ≥ 30 x 10 9L; for pre-
treatment platelet count of < 20 x 10 9L, platelet
absolute increase of ≥ 20 x 10 9L and ≥ 100% from pretreatment level - Go to question 572
☐ HI-N - neutrophil count increase of ≥ 100% from pre-
treatment level and an absolute increase of ≥ 500 / mm3
- Go to question 572
570. Date of progression: ___ ___ ___ ___/ ___ ___ / ___ ___
YYYY
MM
DD
- Go to question 572
571. Date of relapse: ___ ___ ___ ___ / ___ ___ / ___ ___
YYYY
MM
DD
- Go to question 572
572. Date assessed:
☐ Other leukemia (30) (includes CLL)
___ ___ ___ ___ / ___ ___ / ___ ___
YYYY
MM
DD
- Go to First Name
Other Leukemia (OL)
573. Specify the other leukemia classification:
☐ Chronic lymphocytic leukemia (CLL), NOS (34) - Go to question 575
☐ Chronic lymphocytic leukemia (CLL), B-cell/small lymphocytic lymphoma (SLL)
(71) - Go to question 575
☐ Hairy cell leukemia (35) - Go to question 578
CIBMTR Form 2400 revision 4 (page 31 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ Prolymphocytic leukemia (PLL), NOS (37) - Go to question 575
☐ PLL, B-cell (73) - Go to question 575
☐ PLL, T-cell (74) - Go to question 575
☐ Other leukemia, NOS (30) - Go to question 577
☐ Other leukemia (39)
574. Specify other leukemia:_________________
- Go to question 577
575. Was any 17p abnormality detected?
☐ Yes
☐ No
If disease classification is CLL, go to question 576. If PLL, go to
question 578.
576. Did a histologic transformation to diffuse large B-cell lymphoma
(Richter syndrome) occur at any time after CLL diagnosis?
☐ Yes - Go to question 583 - Also complete disease
classification questions 583-585
☐ No - Go to question 578
Status at transplantation:
577. What was the disease status? (Atypical CML)
☐ Primary induction failure
☐ 1 complete remission (no previous bone marrow or
st
extramedullary relapse)
☐ 2 complete remission
☐ ≥ 3 complete remission
☐ 1 relapse
☐ 2 relapse
☐ ≥ 3 relapse
☐ No treatment
nd
rd
st
nd
rd
- Go to question 579
Status at transplantation:
578. What was the disease status? (CLL, PLL, Hairy cell
Leukemia)
☐ Never treated
☐ Complete remission (CR)
☐ Nodular partial remission (nPR)
☐ Partial remission (PR)
☐ No response/stable (NR/SD)
☐ Progression
☐ Relapse (untreated)
579. Date assessed: __ __ __ __ / __ __ / __ __ - Go to First Name
YYYY
MM
DD
CIBMTR Form 2400 revision 4 (page 32 of 45). Last Updated October, 2013..
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
☐ Hodgkin lymphoma (150)
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Hodgkin Lymphoma
580. Specify Hodgkin lymphoma classification:
☐ Nodular lymphocyte predominant Hodgkin lymphoma (155)
☐ Lymphocyte-rich (151)
☐ Nodular sclerosis (152)
☐ Mixed cellularity (153)
☐ Lymphocyte depleted (154)
☐ Hodgkin lymphoma, NOS (150)
Status at transplantation:
581. What was the disease status?
☐ Disease untreated
☐ PIF res - Primary induction failure – resistant: NEVER in COMPLETE remission
but with stable or progressive disease on treatment.
remission but with partial remission on treatment.
☐ PIF sen/PR1 - Primary induction failure – sensitive: NEVER in COMPLETE
☐ PIF unk - Primary induction failure – sensitivity unknown
☐ CR1 - 1 complete remission: no bone marrow or extramedullary relapse prior to
☐ CR2 - 2 complete remission
☐ CR3+ - 3 or subsequent complete remission
☐ REL1 unt - 1 relapse – untreated; includes either bone marrow or extramedullary
☐ REL1 res - 1 relapse – resistant: stable or progressive disease with treatment
☐ REL1 sen - 1 relapse – sensitive: partial remission (if complete remission was
☐ REL1 unk - 1
☐ REL2 unt - 2
st
transplant
nd
rd
st
relapse
st
st
achieved, classify as CR2)
relapse – sensitivity unknown
st
relapse – untreated: includes either bone marrow or extramedullary
nd
relapse
☐
REL2 res - 2
☐ REL2 sen - 2
relapse – resistant: stable or progressive disease with treatment
nd
relapse – sensitive: partial remission (if complete remission
achieved, classify as CR3+)
nd
☐ REL2 unk - 2
☐ REL3+ unt - 3
☐ REL3+ res - 3
nd
relapse – sensitivity unknown
or subsequent relapse – untreated; includes either bone marrow or
extramedullary relapse
rd
rd
or subsequent relapse – resistant: stable or progressive disease
with treatment
or subsequent relapse – sensitive: partial remission (if complete
remission achieved, classify as CR3+)
☐ REL3+ sen - 3
rd
☐
REL3+ unk - 3
rd
relapse or greater – sensitivity unknown
582. Date assessed: __ __ __ __ / __ __ / __ __ - Go to First Name
YYYY
MM
DD
CIBMTR Form 2400 revision 4 (page 33 of 45). Last Updated October, 2013..
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
☐ Non-Hodgkin lymphoma (100)
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Non-Hodgkin Lymphoma
583. Specify Non-Hodgkin lymphoma classification:
☐ Splenic marginal zone B-cell lymphoma (124)
☐ Extranodal marginal zone B-cell lymphoma of mucosal associated lymphoid tissue
type (MALT) (122)
☐ Nodal marginal zone B-cell lymphoma (± monocytoid B-cells) (123)
☐ Follicular, predominantly small cleaved cell (Grade I follicle center lymphoma) (102)
☐ Follicular, mixed, small cleaved and large cell (Grade II follicle center lymphoma)
(103)
☐ Follicular, predominantly large cell (Grade IIIA follicle center lymphoma) (162)
☐ Follicular, predominantly large cell (Grade IIIB follicle center lymphoma) (163)
☐ Follicular (grade unknown) (164)
☐ Mantle cell lymphoma (115)
☐ Intravascular large B-cell lymphoma (136)
☐ Primary mediastinal (thymic) large B-cell lymphoma (125)
☐ Primary effusion lymphoma (138)
☐ Diffuse, large B-cell lymphoma — NOS (107)
☐ Burkitt lymphoma (111)
☐ B-cell lymphoma, unclassifiable, with features intermediate between DLBCL and
Burkitt lymphoma (140)
☐ B-cell lymphoma, unclassifiable, with features intermediate between DLBCL and
classical Hodgkin Lymphoma (149)
☐ T-cell/histiocytic rich large B-cell lymphoma (120)
☐ Primary diffuse large B-cell lymphoma of the CNS (118)
☐ Waldenstrom macroglobulinemia/Lymphoplasmacytic lymphoma (173)
☐ Other B-cell lymphoma (129) – Go to question 584
☐ Extranodal NK/T-cell lymphoma, nasal type (137)
☐ Enteropathy-type T-cell lymphoma (133)
☐ Hepatosplenic T-cell lymphoma (145)
☐ Subcutaneous panniculitis-like T-cell lymphoma (146)
☐ Mycosis fungoides (141)
☐ Sezary syndrome (142)
☐ Primary cutaneous CD30+ T-cell lymphoproliferative disorders [Primary cutaneous
anaplastic large-cell lymphoma (C-ALCL), lymphoid papulosis] (147)
☐ Peripheral T-cell lymphoma (PTCL), NOS (130)
☐ Angioimmunoblastic T-cell lymphoma (131)
☐ Anaplastic large-cell lymphoma (ALCL), ALK positive (143)
☐ Anaplastic large-cell lymphoma (ALCL), ALK negative (144)
☐ T-cell large granular lymphocytic leukemia (126)
☐ Aggressive NK-cell leukemia (27)
☐ Adult T-cell lymphoma/leukemia (HTLV1 associated) (134)
☐ Other T-cell/NK-cell lymphoma (139) - Go to question 584
584. Specify other lymphoma: ______________________________
CIBMTR Form 2400 revision 4 (page 34 of 45). Last Updated October, 2013..
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
585. Is the non-Hodgkin lymphoma histology reported at diagnosis (question 583) a
transformation from CLL?
☐ Yes (Also complete Disease Classification questions 573 - 576)
☐ No
586. Is the non-Hodgkin lymphoma histology reported (in question 583)
a transformation from, or was it diagnosed at the same time as
another lymphoma (not CLL)?
☐ Yes
☐ No
Status at Transplantation
587. What was the disease status?
☐ Disease untreated
☐ PIF res - Primary induction failure – resistant: NEVER in COMPLETE remission
but with stable or progressive disease on treatment.
☐ PIF sen/PR1 - Primary induction failure – sensitive: NEVER in COMPLETE
remission but with partial remission on treatment.
☐ PIF unk - Primary induction failure – sensitivity unknown
☐ CR2 - 2 complete remission
☐ CR3+ - 3 or subsequent complete remission
☐ REL1 unt - 1 relapse – untreated; includes either bone marrow or extramedullary
☐ CR1 - 1st complete remission: no bone marrow or extramedullary relapse prior to
transplant
nd
rd
relapse
☐ REL1 res - relapse – resistant: stable or progressive disease with treatment
☐ REL1 sen - 1 relapse – sensitive: partial remission (if complete remission was
1st
st
st
achieved, classify as CR2)
☐ REL1 unk - 1
☐ REL2 unt - 2
relapse
nd
nd
☐ REL2 res - 2
☐ REL2 sen - 2
relapse – sensitivity unknown
st
relapse – untreated: includes either bone marrow or extramedullary
relapse – resistant: stable or progressive disease with treatment
relapse – sensitive: partial remission (if complete remission
achieved, classify as CR3+)
nd
☐ REL2 unk - 2
☐ REL3+ unt - 3
nd
relapse – sensitivity unknown
or subsequent relapse – untreated; includes either bone marrow or
extramedullary relapse
rd
☐ REL3+ res - 3rd or subsequent relapse – resistant: stable or progressive disease
with treatment
☐ REL3+ sen - 3rd or subsequent relapse – sensitive: partial remission (if complete
remission achieved, classify as CR3+)
☐ REL3+ unk - 3
rd
relapse or greater – sensitivity unknown
588. Date assessed: __ __ __ __ / __ __ / __ __ - Go to First Name
YYYY
MM
DD
CIBMTR Form 2400 revision 4 (page 35 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ Multiple myeloma/plasma cell disorder (PCD) (170)
Multiple Myeloma/Plasma Cell Disorder (PCD)
589. Specify the multiple myeloma/plasma cell disorder (PCD) classification:
☐ Multiple myeloma-lgG (181) - Go to questions 591
☐ Multiple myeloma-lgA (182) - Go to questions 591
☐ Multiple myeloma-lgD (183) - Go to questions 591
☐ Multiple myeloma-lgE (184) - Go to questions 591
☐ Multiple myeloma-lgM (not Waldenstrom macroglobulinemia) (185)
- Go to questions 591
☐
Multiple myeloma-light chain only (186) - Go to questions 591
☐
Multiple myeloma-non-secretory (187) - Go to questions 592
☐
Plasma cell leukemia (172) - Go to question 597
☐
Solitary plasmacytoma (no evidence of myeloma) (175) - Go to question 597
☐
Amyloidosis (174) - Go to question 597
☐
Osteosclerotic myeloma/POEMS syndrome (176) - Go to question 597
☐
Light chain deposition disease (177) - Go to question 597
☐
Other plasma cell disorder (179) - Go to question 590
590. Specify other plasma cell disorder:_______________________
- Go to question 597
591. Light chain
☐ kappa
☐ lambda
592. What was the Durie-Salmon staging (at diagnosis)?
☐
Stage I (All of the following: Hgb > 10g/dL; serum calcium
normal or <10.5 mg/dL; bone x-ray normal bone structure
(scale 0), or solitary bone plasmacytoma only; low
M-component production rates IgG < 5g/dL, IgA < 3g/dL;
urine light chain M-component on electrophoresis
<4g/24h) - Go to questions 593
☐
Stage II (Fitting neither Stage I or Stage III)
- Go to questions 593
☐ Stage III (One of more of the following: Hgb <8.5 g/dL;
serum calcium > 12 mg/dL; advanced lytic bone lesions
(scale 3); high M-component production rates IgG >7g/dL,
IgA > 5g/dL; Bence Jones protein >12g/24h)
- Go to questions 593
☐ Unknown - Go to questions 594
593. What was the Durie-Salmon sub
classification (at diagnosis)?
☐ A - relatively normal renal function
(serum creatinine < 2.0 mg/dL)
☐ B - abnormal renal function (serum
creatinine ≥ 2.0 mg/dL)
I.S.S.:
594. Serum β2-microglobulin:
___ ___ ___ ● ___ ___ ___
☐ μg/dL ☐ mg/L
595. Serum albumin: ___ ___ ● ___
CIBMTR Form 2400 revision 4 (page 36 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
☐ g/dL
☐ g/L
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
596. Stage
☐
1 (β -mic < 3.5, S. albumin > 3.5)
☐
2 (β -mic 3.5–< 5.5, S. albumin —)
☐
3 (β -mic ≥ 5.5; S. albumin —)
2
2
2
597. Were cytogenetics tested (conventional or FISH)?
☐ Yes
598. Results of tests:
☐ No
☐ Abnormalities identified
☐ Unknown
☐ No evaluable metaphases
☐ No abnormalities
Specify cytogenetic abnormalities identified at
any time prior to the start of the preparative
regimen:
Trisomy
599. +3
600. +5
601. +7
602. +9
603. +11
604. +15
605. +19
Translocation
606. t(4;14)
607. t(6;14)
608. t(11;14)
609. t(14;16)
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ No
☐ No
☐ No
☐ No
☐ No
☐ Yes
☐ Yes
☐ No
☐ No
☐ Yes
☐ Yes
615. Any abnormality at 1q ☐ Yes
616. Any abnormality at 1p ☐ Yes
☐ No
☐ No
☐ No
☐ No
617. Other abnormality
610. t(14;20)
Deletion
611. del 13/13q-
612. del 17/17p-
Other
613. Hyperdiploid (>50)
614. Hypodiploid (<46)
☐ Yes
618. Specify other abnormality:
☐ No
____________________
Status at transplantation:
619. What was the disease status?
☐ Stringent complete remission (sCR) - CR as defined, plus: normal free light
chain ratio, and absence of clonal cells in the bone marrow by
CIBMTR Form 2400 revision 4 (page 37 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
immunohistochemistry or immunofluorescence (confirmation
with repeat bone marrow biopsy not needed). (Presence and/or absence
of clonal cells is based upon the κ/λ ratio. An abnormal κ/λ ratio by
immunohistochemistry and/or immunofluorescence requires a minimum of
100 plasma cells for analysis. An abnormal ratio reflecting the presence of
an abnormal clone is κ/λ of > 4:1 or < 1:2.) sCR requires two consecutive
assessments made at any time before the institution of any new therapy, and
no known evidence of progressive or new bone lesions if radiographic
studies were performed; radiographic studies are not required to satisfy sCR
requirements.
☐ Complete remission (CR) - negative immunofixation on serum and urine
samples, and disappearance of any soft tissue plasmacytomas, and ≤ 5%
plasma cells in the bone marrow (confirmation with repeat bone marrow
biopsy not needed). CR requires two consecutive assessments made at any
time before the institution of any new therapy, and no known evidence of
progressive or new bone lesions if radiographic studies were performed;
radiographic studies are not required to satisfy CR requirements.
☐ Near complete remission (nCR) - serum & urine M-protein detectable by
immunoelectrophoresis (IFE), but not on electrophoresis (negative SPEP &
UPEP); ≤ 5% plasma cells in bone marrow. nCR requires two consecutive
assessments made at any time before the initiation of any new therapy, and
no known evidence of progressive or new bone lesions if radiographic
studies were performed; radiographic studies are not required to satisfy
nCR requirements.
☐ Very good partial remission (VGPR) - serum and urine M-protein detectable
by immunofixation but not on electrophoresis, or ≥ 90% reduction in serum
M-protein and urine M-protein level < 100 mg/24 hours. VGPR requires two
consecutive assessments made at any time before the institution of any new
therapy, and no known evidence of progressive or new bone lesions if
radiographic studies were performed; radiographic studies are not required
to satisfy VGPR requirements.
☐ Partial remission (PR) - ≥ 50% reduction in serum M-protein, and reduction in
24-hour urinary M-protein by ≥ 90% or to < 200 mg/24 hours. If the serum
and urine M-protein are unmeasurable (i.e., do not meet any of the following
criteria: • serum M-protein ≥ 1 g/dL. Urine M-protein ≥ 200 mg/24 hours •
serum free light chain assay shows involved level ≥ 10 mg/dL, provided
serum free light chain ratio is abnormal), a ≥ 50% decrease in the difference
between involved and uninvolved free light chain levels is required in place
of the M-protein criteria. If serum and urine M-protein are unmeasurable, and
serum free light assay is also unmeasurable, a ≥ 50% reduction in plasma
cells is required in place of M-protein, provided the baseline bone marrow
plasma cell percentage was ≥ 30%. In addition to the above listed criteria,
a ≥ 50% reduction in the size of soft tissue plasmacytomas is also required,
if present at baseline. PR requires two consecutive assessments made at any
time before the institution of any new therapy, and no known evidence of
progressive or new bone lesions if radiographic studies were performed;
radiographic studies are not required to satisfy PR requirements.
☐ Stable disease (SD) - not meeting the criteria for CR, VGPR, PR or PD. SD
requires two consecutive assessments made at any time before the
institution of any new therapy, and no known evidence of progressive or
new bone lesions if radiographic studies were performed; radiographic
studies are not required to satisfy SD requirements.
☐ Progressive disease (PD) - requires any one or more of the following: Increase
of ≥ 25% from baseline in: serum M-component and/or (absolute increase ≥
0.5 g/dL) (for progressive disease, serum M-component increases of ≥ 1 g/dL
are sufficient to define relapse if the starting M-component is ≥ 5 g/dL). Urine
M-component and/or (absolute increase ≥ 200 mg. 24 hours) for recipients
without measurable serum and urine M-protein levels: the difference
between involved and uninvolved free light chain levels (absolute increase >
10 mg/dL). Bone marrow plasma cell percentage (absolute percentage ≥
10%) (relapse from CR has a 5% cutoff vs. 10% for other categories of
relapse) definite development of new bone lesions or soft tissue
plasmacytomas, or definite increase in the size of any existing bone lesions
CIBMTR Form 2400 revision 4 (page 38 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
or soft tissue plasmacytomas. Development of hypercalcemia (corrected
serum calcium > 11.5 mg/dL or 2.65 mmol) that can be attributed solely to
the plasma cell proliferative disorder PD requires two consecutive
assessments made at any time before classification as disease progression,
and/or the institution of any new therapy
☐ Relapse from CR (Rel) (untreated) - requires one or more of the following:
reappearance of serum or urine M-protein by immunofixation or
electrophoresis development of ≥ 5% plasma cells in the bone marrow
(relapse from CR has a 5% cutoff vs. 10% for other categories of relapse)
appearance of any other sign of progression (e.g., new plasmacytoma, lytic
bone lesion, hypercalcemia) Rel requires two consecutive assessments
made at any time before classification as relapse, and/or the institution of
any new therapy.
☐ Unknown
☐ Not applicable - (Amyloidosis with no evidence of myeloma)
620. Date assessed: __ __ __ __ / __ __ / __ __ - Go to First Name
YYYY
MM
DD
☐ Solid tumors (200)
Solid Tumors
621. Specify the solid tumor classification:
☐ Breast cancer (250)
☐ Lung, small cell (202)
☐ Lung, non-small cell (203)
☐ Lung, not otherwise specified (230)
☐ Germ cell tumor, extragonadal (225)
☐ Testicular (210)
☐ Ovarian (epithelial) (214)
☐ Bone sarcoma (excluding Ewing family tumors) (273)
☐ Ewing family tumors of bone (including PNET) (275)
☐ Ewing family tumors, extraosseous (including PNET) (276)
☐ Fibrosarcoma (244)
☐ Hemangiosarcoma (246)
☐ Leiomyosarcoma (242)
☐ Liposarcoma (243)
☐ Lymphangio sarcoma (247)
☐ Neurogenic sarcoma (248)
☐ Rhabdomyosarcoma (232)
☐ Synovial sarcoma (245)
☐ Soft tissue sarcoma (excluding Ewing family tumors) (274)
☐ Central nervous system tumor, including CNS PNET (220)
☐ Medulloblastoma (226)
☐ Neuroblastoma (222)
☐ Head/neck (201)
☐ Mediastinal neoplasm (204)
☐ Colorectal (228)
☐ Gastric (229)
☐ Pancreatic (206)
CIBMTR Form 2400 revision 4 (page 39 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ Hepatobiliary (207)
☐ Prostate (209)
☐ External genitalia (211)
☐ Cervical (212)
☐ Uterine (213)
☐ Vaginal (215)
☐ Melanoma (219)
☐ Wilm tumor (221)
☐ Retinoblastoma (223)
☐ Thymoma (231)
☐ Renal cell (208)
☐ Other solid tumor (269)
622. Specify other solid tumor:________________________________
☐ Solid tumor, not otherwise specified (200)
- Go to First Name
☐ Severe aplastic anemia (300) (If the recipient developed MDS or AML, indicate MDS or AML as the primary disease)
Severe Aplastic Anemia
623. Specify the severe aplastic anemia classification:
☐ Acquired severe aplastic anemia, not otherwise specified (301)
☐ Acquired SAA secondary to hepatitis (302)
☐ Acquired SAA secondary to toxin / other drug (303)
☐ Acquired amegakaryocytosis (not congenital) (304)
☐ Acquired pure red cell aplasia (not congenital) (306)
☐ Dyskeratosis congenita (307)
☐ Other acquired cytopenic syndrome (309)
624. Specify other acquired cytopenic syndrome:
_____________________________________________________
- Go to First Name
CIBMTR Form 2400 revision 4 (page 40 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ Inherited abnormalities of erythrocyte differentiation or function (310)
Inherited Abnormalities of Erythrocyte Differentiation or Function
625. Specify the inherited abnormalities of erythrocyte differentiation or
function classification:
☐ Paroxysmal nocturnal hemoglobinuria (PNH) (56)
☐ Shwachman-Diamond (305)
☐ Diamond-Blackfan anemia (pure red cell aplasia) (312)
☐ Other constitutional anemia (319)
626. Specify other constitutional anemia:________________________
☐ Fanconi anemia (311) (If the recipient developed MDS or AML, indicate MDS or
AML as the primary disease).
☐ Sickle thalassemia (355)
☐ Sickle cell disease (356)
☐ Beta thalassemia major (357)
☐ Other hemoglobinopathy (359)
627. Specify other hemoglobinopathy:__________________________
- Go to First Name
☐ Disorders of the immune system (400)
Disorders of the immune system
628. Specify disorder of immune system classification:
☐ Adenosine deaminase (ADA) deficiency/severe combined immunodeficiency
(SCID) (401)
☐ Absence of T and B cells SCID (402)
☐ Absence of T, normal B cell SCID (403)
☐ Omenn syndrome (404)
☐ Reticular dysgenesis (405)
☐ Bare lymphocyte syndrome (406)
☐ Other SCID (419)
☐ SCID, not otherwise specified (410)
☐ Ataxia telangiectasia (451)
☐ HIV infection (452)
☐ DiGeorge anomaly (454)
☐ Common variable immunodeficiency (457)
☐ Leukocyte adhesion deficiencies, including GP180, CD-18, LFA and WBC
629. Specify other SCID:_____________________________________
adhesion deficiencies (459)
☐ Kostmann agranulocytosis (congenital neutropenia) (460)
☐ Neutrophil actin deficiency (461)
☐ Cartilage-hair hypoplasia (462)
☐ CD40 ligand deficiency (464)
CIBMTR Form 2400 revision 4 (page 41 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ Other immunodeficiencies (479)
630. Specify other immunodeficiency: ___________________________
☐ Immune deficiency, not otherwise specified (400)
☐ Chediak-Higashi syndrome (456)
☐ Griscelli syndrome type 2 (465)
☐ Hermansky-Pudlak syndrome type 2 (466)
☐ Chronic granulomatous disease (455)
☐ Wiskott-Aldrich syndrome (453)
☐ X-linked lymphoproliferative syndrome (458)
- Go to First Name
☐ Inherited abnormalities of platelets (500)
Inherited abnormalities of platelets
631. Specify inherited abnormalities of platelets classification:
☐ Congenital amegakaryocytosis/congenital thrombocytopenia (501)
☐ Glanzmann thrombasthenia (502)
☐ Other inherited platelet abnormality (509)
632. Specify other inherited platelet abnormality:
____________________________________________________
- Go to First Name
☐ Inherited disorders of metabolism (520)
Inherited Disorders of Metabolism
633. Specify inherited disorders of metabolism classification:
☐ Osteopetrosis (malignant infantile osteopetrosis) (521)
Leukodystrophies
☐ Metachromatic leukodystrophy (MLD) (542)
☐ Adrenoleukodystrophy (ALD) (543)
☐ Krabbe disease (globoid leukodystrophy) (544)
☐ Lesch-Nyhan (HGPRT deficiency) (522)
☐ Neuronal ceroid lipofuscinosis (Batten disease) (523)
Mucopolysaccharidoses
☐ Hurler syndrome (IH) (531)
☐ Scheie syndrome (IS) (532)
☐ Hunter syndrome (II) (533)
☐ Sanfilippo (III) (534)
☐ Morquio (IV) (535)
☐ Maroteaux-Lamy (VI) (536)
CIBMTR Form 2400 revision 4 (page 42 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ β-glucuronidase deficiency (VII) (537)
☐ Mucopolysaccharidosis (V) (538)
☐ Mucopolysaccharidosis, not otherwise specified (530)
Mucolipidoses
☐ Gaucher disease (541)
☐ Niemann-Pick disease (545)
☐ I-cell disease (546)
☐ Wolman disease (547)
☐ Glucose storage disease (548)
☐ Mucolipidoses, not otherwise specified (540)
Polysaccharide hydrolase abnormalities
☐ Aspartyl glucosaminidase (561)
☐ Fucosidosis (562)
☐ Mannosidosis (563)
☐ Polysaccharide hydrolase abnormality, not otherwise specified (560)
☐ Other inherited metabolic disorder (529)
634. Specify other inherited metabolic disorder:
_____________________________________________________
☐ Inherited metabolic disorder, not otherwise specified (520)
- Go to First Name
☐ Histiocytic disorders (570)
Histiocytic disorders
635. Specify histiocytic disorder classification:
☐ Hemophagocytic lymphohistiocytosis (HLH) (571)
☐ Langerhans cell histiocytosis (histiocytosis-X) (572)
☐ Hemophagocytosis (reactive or viral associated) (573)
☐ Malignant histiocytosis (574)
☐ Other histiocytic disorder (579)
636. Specify other inherited metabolic disorder:
_____________________________________________________
☐ Histiocytic disorder, not otherwise specified (570)
- Go to First Name
CIBMTR Form 2400 revision 4 (page 43 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
☐ Autoimmune diseases (600)
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Autoimmune diseases
637. Specify autoimmune disease classification:
Arthritis
☐ Rheumatoid arthritis (603)
☐ Psoriatic arthritis/psoriasis (604)
☐ Juvenile idiopathic arthritis (JIA): systemic (Stills disease) (640)
☐ JIA: oligoarticular (641)
☐ Juvenile idiopathic arthritis (JIA): other (643)
638. Specify other arthritis:___________________________________
☐ Other arthritis (633)
639. Specify other juvenile idiopathic arthritis (JIA):
_____________________________________________________
Multiple sclerosis
☐ Multiple sclerosis (602)
Connective tissue diseases
☐ Systemic sclerosis (scleroderma) (607)
☐ Systemic lupus erythematosis (SLE) (605)
☐ Sjögren syndrome (608)
☐ Polymyositis/dermatomyositis (606)
☐ Antiphospholipid syndrome (614)
☐ Other connective tissue disease (634)
640. Specify other connective tissue disease:
_____________________________________________________
Vasculitis
☐ Wegener granulomatosis (610)
☐ Classical polyarteritis nodosa (631)
☐ Microscopic polyarteritis nodosa (632)
☐ Churg-Strauss (635)
☐ Giant cell arteritis (636)
☐ Takayasu (637)
☐ Behcet syndrome (638)
☐ Overlap necrotizing arteritis (639)
☐ Other vasculitis (611)
641. Specify other vasculitis:__________________________________
Other neurological autoimmune diseases
☐ Myasthenia gravis (601)
☐ Other autoimmune neurological disorder (644)
642. Specify other autoimmune neurological disorder:
_____________________________________________________
CIBMTR Form 2400 revision 4 (page 44 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Hematological autoimmune diseases
☐ Idiopathic thrombocytopenic purpura (ITP) (645)
☐ Hemolytic anemia (646)
☐ Evan syndrome (647)
☐ Other autoimmune cytopenia (648)
643. Specify other autoimmune cytopenia:
_____________________________________________________
Bowel diseases
☐ Crohn’s disease (649)
☐ Ulcerative colitis (650)
☐ Other autoimmune bowel disorder (651)
644. Specify other autoimmune bowel disorder:
_____________________________________________________
- Go to First Name
☐ Other disease (900)
Other Disease
645. Specify other disease:__________________________________________________
First Name:_____________________________________________________
Last Name:_____________________________________________________
E-mail address:__________________________________________________
Date: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
CIBMTR Form 2400 revision 4 (page 45 of 45). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
| File Type | application/pdf |
| File Modified | 2013-11-06 |
| File Created | 2013-11-04 |