27 Adult Post Transplant Malignancy Worksheet

Records
Adult Post-Transplant Malignancy Worksheet
FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 12/31/2011
Note: These worksheets are provided to function as a guide to what data will be required in the online TIEDI ® application. Currently
in the worksheet, a 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:

Immunosuppression Stopped
Immunosuppression:

Immunosuppression Reduced
No Immunosuppression Adjustment

Tumor type:
Primary to the transplanted organ
Not primary to the transplanted organ
Specify treatment:
Surgical resection tumor
Chemotherapy:
Other specify:

Radiation

Immunotherapy:

Hormonal Therapy

Interferon Alpha
Prednisone
Rituximab
Other, specify
Other specify:
Other treatment specify:

Alive, Free of Tumor
Alive with Tumor
Outcome:
Dead, due to tumor
Dead, other causes

RECURRENCE OF PRETRANSPLANT MALIGNANCY
Type of pre-existing tumor:

If skin # of occurrences in follow-up period:

A
B
If Color-rectal, Duke's Classificiation:
C
Unknown
If Lymphoma specify type:

AML
ALL
If Leukemia:

MDS
CML
CLL

Other
If other cancer, specify:

Treatments of pre-existing tumor:
Treatment date:

Biopsy
Resection
Surgery:
Limited Resection; debulking
Other, specify
Other specify:

Chemotherapy:
Other specify:

Radiation
Other treatment specify:

Date of recurrence (post tx):
Site(s) affected:
Primary organ

Regional lymph nodes

Adjacent organs

Distant metastases

Immunosuppression Stopped
Immunosuppression:

Immunosuppression Reduced
No Immunosuppression Adjustment

Treatments of recurrent tumor:

Biopsy
Surgery:
Resection

Limited Resection; debulking
Other, specify
Other specify:

Chemotherapy:
Other specify:

Radiation

Hormonal Therapy
Interferon Alpha
Prednisone

Immunotherapy:

Rituximab
Other, specify
Other specify:
Other treatment specify:

Alive, Free of Tumor
Alive with Tumor
Outcome:
Dead, due to tumor
Dead, other causes

POST TRANSPLANT DE NOVO SOLID TUMOR
Select one or more tumor types:
Skin, squamous cell:
Sites:

Site Location:
Spread:

Single

Multiple

Lips/Head/Neck
None

Nodes

Extremities
Other:

Trunk

# of Occurrences:

ST=

Treatment Information:
Site(s) affected:
Primary organ

Regional lymph nodes

Adjacent organs

Distant metastases

Diagnosis date:

Immunosuppression Stopped
Immunosuppression:

Immunosuppression Reduced
No Immunosuppression Adjustment

Specify treatment:

Biopsy
Resection
Surgery:
Limited Resection; debulking
Other, specify
Other specify:

Cryotherapy (skin cancer)
Chemotherapy:
Other specify:

Hormonal Therapy
Interferon Alpha
Immunotherapy:

Prednisone
Rituximab
Other, specify

Other specify:

Radiation

Other treatment:
Best treatment response:
Progressive disease (PD)
Partial response (PR)
No treatment (NT)
Too early in treatment to evaluate (TE)
Stable disease (SD)
Complete response (CR)

Skin, basal cell:
Sites:

Site Location:
Spread:

Single

Multiple

Lips/Head/Neck
None

# of Occurrences:

Extremities

Nodes

Trunk

Other:

ST=

Treatment Information:
Site(s) affected:
Primary organ

Regional lymph nodes

Adjacent organs

Distant metastases

Diagnosis date:

Immunosuppression Stopped
Immunosuppression:

Immunosuppression Reduced
No Immunosuppression Adjustment

Specify treatment:

Biopsy
Surgery:
Resection

Limited Resection; debulking
Other, specify
Other specify:

Cryotherapy (skin cancer)
Chemotherapy:
Other specify:

Hormonal Therapy
Interferon Alpha
Prednisone

Immunotherapy:

Rituximab
Other, specify
Other specify:

Radiation
Other treatment:
Best treatment response:
Progressive disease (PD)
Partial response (PR)
No treatment (NT)
Too early in treatment to evaluate (TE)
Stable disease (SD)
Complete response (CR)

Skin, melanoma:
Sites:

Site Location:

Single

Multiple

Lips/Head/Neck

Extremities

Trunk

Spread:

None

# of Occurrences:

Nodes

Other:

ST=

Treatment Information:
Site(s) affected:
Primary organ

Regional lymph nodes

Adjacent organs

Distant metastases

Diagnosis date:

Immunosuppression Stopped
Immunosuppression:

Immunosuppression Reduced
No Immunosuppression Adjustment

Specify treatment:

Biopsy
Resection
Surgery:
Limited Resection; debulking
Other, specify
Other specify:

Cryotherapy (skin cancer)
Chemotherapy:
Other specify:

Hormonal Therapy
Interferon Alpha
Immunotherapy:

Prednisone
Rituximab
Other, specify

Other specify:

Radiation
Other treatment:
Best treatment response:
Progressive disease (PD)
Partial response (PR)
No treatment (NT)
Too early in treatment to evaluate (TE)
Stable disease (SD)
Complete response (CR)

Kaposi's sarcoma: cutaneous:
Treatment Information:
Site(s) affected:
Primary organ

Regional lymph nodes

Adjacent organs

Distant metastases

Diagnosis date:

Immunosuppression Stopped
Immunosuppression:

Immunosuppression Reduced
No Immunosuppression Adjustment

Specify treatment:

Biopsy
Resection
Surgery:
Limited Resection; debulking
Other, specify
Other specify:

Cryotherapy (skin cancer)

Chemotherapy:
Other specify:

Hormonal Therapy
Interferon Alpha
Immunotherapy:

Prednisone
Rituximab
Other, specify

Other specify:

Radiation
Other treatment:
Best treatment response:
Progressive disease (PD)
Partial response (PR)
No treatment (NT)
Too early in treatment to evaluate (TE)
Stable disease (SD)
Complete response (CR)

Kaposi's sarcoma: visceral:
Treatment Information:
Site(s) affected:
Primary organ

Regional lymph nodes

Adjacent organs

Distant metastases

Diagnosis date:

Immunosuppression:

Immunosuppression Stopped

Immunosuppression Reduced
No Immunosuppression Adjustment
Specify treatment:

Biopsy
Resection
Surgery:
Limited Resection; debulking
Other, specify
Other specify:

Cryotherapy (skin cancer)
Chemotherapy:
Other specify:

Hormonal Therapy
Interferon Alpha
Immunotherapy:

Prednisone
Rituximab
Other, specify

Other specify:

Radiation
Other treatment:
Best treatment response:
Progressive disease (PD)
Partial response (PR)
No treatment (NT)
Too early in treatment to evaluate (TE)
Stable disease (SD)

Complete response (CR)

Astrocytoma
Medulloblastoma
Glioblastoma Multiforme
Neuroblastoma
Brain:
Meningioma,Malignant
Meningioma,Benign
Angioblastoma
Other Specify
Other specify:
Treatment Information:
Site(s) affected:
Primary organ

Regional lymph nodes

Adjacent organs

Distant metastases

Diagnosis date:

Immunosuppression Stopped
Immunosuppression:

Immunosuppression Reduced
No Immunosuppression Adjustment

Specify treatment:

Biopsy
Resection
Surgery:
Limited Resection; debulking
Other, specify

Other specify:

Cryotherapy (skin cancer)
Chemotherapy:
Other specify:

Hormonal Therapy
Interferon Alpha
Immunotherapy:

Prednisone
Rituximab
Other, specify

Other specify:

Radiation
Other treatment:
Best treatment response:
Progressive disease (PD)
Partial response (PR)
No treatment (NT)
Too early in treatment to evaluate (TE)
Stable disease (SD)
Complete response (CR)

Renal carcinoma - specify site(s):
Renal carcinoma:
Treatment Information:
Site(s) affected:
Primary organ

Regional lymph nodes

Adjacent organs

Distant metastases

Diagnosis date:

Immunosuppression Stopped
Immunosuppression:

Immunosuppression Reduced
No Immunosuppression Adjustment

Specify treatment:

Biopsy
Resection
Surgery:
Limited Resection; debulking
Other, specify
Other specify:

Cryotherapy (skin cancer)
Chemotherapy:
Other specify:

Hormonal Therapy
Interferon Alpha
Immunotherapy:

Prednisone
Rituximab
Other, specify

Other specify:

Radiation
Other treatment:
Best treatment response:
Progressive disease (PD)
Partial response (PR)
No treatment (NT)

Too early in treatment to evaluate (TE)
Stable disease (SD)
Complete response (CR)

Carcinoma of vulva, perineum or penis, scrotum:
Treatment Information:
Site(s) affected:
Primary organ

Regional lymph nodes

Adjacent organs

Distant metastases

Diagnosis date:

Immunosuppression Stopped
Immunosuppression:

Immunosuppression Reduced
No Immunosuppression Adjustment

Specify treatment:

Biopsy
Resection
Surgery:
Limited Resection; debulking
Other, specify
Other specify:

Cryotherapy (skin cancer)
Chemotherapy:
Other specify:

Hormonal Therapy
Immunotherapy:

Interferon Alpha
Prednisone

Rituximab
Other, specify
Other specify:

Radiation
Other treatment:
Best treatment response:
Progressive disease (PD)
Partial response (PR)
No treatment (NT)
Too early in treatment to evaluate (TE)
Stable disease (SD)
Complete response (CR)

Cervix, invasive
Carcinoma of the uterus:

Cervix, in situ
Body, endometrium

Treatment Information:
Site(s) affected:
Primary organ

Regional lymph nodes

Adjacent organs

Distant metastases

Diagnosis date:

Immunosuppression Stopped
Immunosuppression:

Immunosuppression Reduced
No Immunosuppression Adjustment

Specify treatment:

Biopsy
Resection
Surgery:
Limited Resection; debulking
Other, specify
Other specify:

Cryotherapy (skin cancer)
Chemotherapy:
Other specify:

Hormonal Therapy
Interferon Alpha
Immunotherapy:

Prednisone
Rituximab
Other, specify

Other specify:

Radiation
Other treatment:
Best treatment response:
Progressive disease (PD)
Partial response (PR)
No treatment (NT)
Too early in treatment to evaluate (TE)
Stable disease (SD)
Complete response (CR)

Ovarian:

Treatment Information:
Site(s) affected:
Primary organ

Regional lymph nodes

Adjacent organs

Distant metastases

Diagnosis date:

Immunosuppression Stopped
Immunosuppression:

Immunosuppression Reduced
No Immunosuppression Adjustment

Specify treatment:

Biopsy
Resection
Surgery:
Limited Resection; debulking
Other, specify
Other specify:

Cryotherapy (skin cancer)
Chemotherapy:
Other specify:

Hormonal Therapy
Interferon Alpha
Immunotherapy:

Prednisone
Rituximab
Other, specify

Other specify:

Radiation
Other treatment:

Best treatment response:
Progressive disease (PD)
Partial response (PR)
No treatment (NT)
Too early in treatment to evaluate (TE)
Stable disease (SD)
Complete response (CR)

Testicular:
Treatment Information:
Site(s) affected:
Primary organ

Regional lymph nodes

Adjacent organs

Distant metastases

Diagnosis date:

Immunosuppression Stopped
Immunosuppression:

Immunosuppression Reduced
No Immunosuppression Adjustment

Specify treatment:

Biopsy
Resection
Surgery:
Limited Resection; debulking
Other, specify
Other specify:

Cryotherapy (skin cancer)
Chemotherapy:
Other specify:

Hormonal Therapy
Interferon Alpha
Immunotherapy:

Prednisone
Rituximab
Other, specify

Other specify:

Radiation
Other treatment:
Best treatment response:
Progressive disease (PD)
Partial response (PR)
No treatment (NT)
Too early in treatment to evaluate (TE)
Stable disease (SD)
Complete response (CR)

Esophagus:
Treatment Information:
Site(s) affected:
Primary organ

Regional lymph nodes

Adjacent organs

Distant metastases

Diagnosis date:

Immunosuppression Stopped
Immunosuppression:

Immunosuppression Reduced
No Immunosuppression Adjustment

Specify treatment:

Biopsy
Resection
Surgery:
Limited Resection; debulking
Other, specify
Other specify:

Cryotherapy (skin cancer)
Chemotherapy:
Other specify:

Hormonal Therapy
Interferon Alpha
Immunotherapy:

Prednisone
Rituximab
Other, specify

Other specify:

Radiation
Other treatment:
Best treatment response:
Progressive disease (PD)
Partial response (PR)
No treatment (NT)
Too early in treatment to evaluate (TE)
Stable disease (SD)
Complete response (CR)

Stomach:

Treatment Information:
Site(s) affected:
Primary organ

Regional lymph nodes

Adjacent organs

Distant metastases

Diagnosis date:

Immunosuppression Stopped
Immunosuppression:

Immunosuppression Reduced
No Immunosuppression Adjustment

Specify treatment:

Biopsy
Resection
Surgery:
Limited Resection; debulking
Other, specify
Other specify:

Cryotherapy (skin cancer)
Chemotherapy:
Other specify:

Hormonal Therapy
Interferon Alpha
Immunotherapy:

Prednisone
Rituximab
Other, specify

Other specify:

Radiation
Other treatment:

Best treatment response:
Progressive disease (PD)
Partial response (PR)
No treatment (NT)
Too early in treatment to evaluate (TE)
Stable disease (SD)
Complete response (CR)

Small intestine:
Treatment Information:
Site(s) affected:
Primary organ

Regional lymph nodes

Adjacent organs

Distant metastases

Diagnosis date:

Immunosuppression Stopped
Immunosuppression:

Immunosuppression Reduced
No Immunosuppression Adjustment

Specify treatment:

Biopsy
Resection
Surgery:
Limited Resection; debulking
Other, specify
Other specify:

Cryotherapy (skin cancer)
Chemotherapy:
Other specify:

Hormonal Therapy
Interferon Alpha
Immunotherapy:

Prednisone
Rituximab
Other, specify

Other specify:

Radiation
Other treatment:
Best treatment response:
Progressive disease (PD)
Partial response (PR)
No treatment (NT)
Too early in treatment to evaluate (TE)
Stable disease (SD)
Complete response (CR)

Pancreas:
Treatment Information:
Site(s) affected:
Primary organ

Regional lymph nodes

Adjacent organs

Distant metastases

Diagnosis date:

Immunosuppression Stopped
Immunosuppression:

Immunosuppression Reduced
No Immunosuppression Adjustment

Specify treatment:

Biopsy
Resection
Surgery:
Limited Resection; debulking
Other, specify
Other specify:

Cryotherapy (skin cancer)
Chemotherapy:
Other specify:

Hormonal Therapy
Interferon Alpha
Immunotherapy:

Prednisone
Rituximab
Other, specify

Other specify:

Radiation
Other treatment:
Best treatment response:
Progressive disease (PD)
Partial response (PR)
No treatment (NT)
Too early in treatment to evaluate (TE)
Stable disease (SD)
Complete response (CR)

Larynx:

Treatment Information:
Site(s) affected:
Primary organ

Regional lymph nodes

Adjacent organs

Distant metastases

Diagnosis date:

Immunosuppression Stopped
Immunosuppression:

Immunosuppression Reduced
No Immunosuppression Adjustment

Specify treatment:

Biopsy
Resection
Surgery:
Limited Resection; debulking
Other, specify
Other specify:

Cryotherapy (skin cancer)
Chemotherapy:
Other specify:

Hormonal Therapy
Interferon Alpha
Immunotherapy:

Prednisone
Rituximab
Other, specify

Other specify:

Radiation
Other treatment:

Best treatment response:
Progressive disease (PD)
Partial response (PR)
No treatment (NT)
Too early in treatment to evaluate (TE)
Stable disease (SD)
Complete response (CR)

Tongue, throat:
Treatment Information:
Site(s) affected:
Primary organ

Regional lymph nodes

Adjacent organs

Distant metastases

Diagnosis date:

Immunosuppression Stopped
Immunosuppression:

Immunosuppression Reduced
No Immunosuppression Adjustment

Specify treatment:

Biopsy
Resection
Surgery:
Limited Resection; debulking
Other, specify
Other specify:

Cryotherapy (skin cancer)
Chemotherapy:
Other specify:

Hormonal Therapy
Interferon Alpha
Immunotherapy:

Prednisone
Rituximab
Other, specify

Other specify:

Radiation
Other treatment:
Best treatment response:
Progressive disease (PD)
Partial response (PR)
No treatment (NT)
Too early in treatment to evaluate (TE)
Stable disease (SD)
Complete response (CR)

Thyroid:
Treatment Information:
Site(s) affected:
Primary organ

Regional lymph nodes

Adjacent organs

Distant metastases

Diagnosis date:

Immunosuppression Stopped
Immunosuppression:

Immunosuppression Reduced
No Immunosuppression Adjustment

Specify treatment:

Biopsy
Resection
Surgery:
Limited Resection; debulking
Other, specify
Other specify:

Cryotherapy (skin cancer)
Chemotherapy:
Other specify:

Hormonal Therapy
Interferon Alpha
Immunotherapy:

Prednisone
Rituximab
Other, specify

Other specify:

Radiation
Other treatment:
Best treatment response:
Progressive disease (PD)
Partial response (PR)
No treatment (NT)
Too early in treatment to evaluate (TE)
Stable disease (SD)
Complete response (CR)

Bladder:

Treatment Information:
Site(s) affected:
Primary organ

Regional lymph nodes

Adjacent organs

Distant metastases

Diagnosis date:

Immunosuppression Stopped
Immunosuppression:

Immunosuppression Reduced
No Immunosuppression Adjustment

Specify treatment:

Biopsy
Resection
Surgery:
Limited Resection; debulking
Other, specify
Other specify:

Cryotherapy (skin cancer)
Chemotherapy:
Other specify:

Hormonal Therapy
Interferon Alpha
Immunotherapy:

Prednisone
Rituximab
Other, specify

Other specify:

Radiation
Other treatment:

Best treatment response:
Progressive disease (PD)
Partial response (PR)
No treatment (NT)
Too early in treatment to evaluate (TE)
Stable disease (SD)
Complete response (CR)

Breast:
Treatment Information:
Site(s) affected:
Primary organ

Regional lymph nodes

Adjacent organs

Distant metastases

Diagnosis date:

Immunosuppression Stopped
Immunosuppression:

Immunosuppression Reduced
No Immunosuppression Adjustment

Specify treatment:

Biopsy
Resection
Surgery:
Limited Resection; debulking
Other, specify
Other specify:

Cryotherapy (skin cancer)
Chemotherapy:
Other specify:

Hormonal Therapy
Interferon Alpha
Immunotherapy:

Prednisone
Rituximab
Other, specify

Other specify:

Radiation
Other treatment:
Best treatment response:
Progressive disease (PD)
Partial response (PR)
No treatment (NT)
Too early in treatment to evaluate (TE)
Stable disease (SD)
Complete response (CR)

Prostate:
Treatment Information:
Site(s) affected:
Primary organ

Regional lymph nodes

Adjacent organs

Distant metastases

Diagnosis date:

Immunosuppression Stopped
Immunosuppression:

Immunosuppression Reduced
No Immunosuppression Adjustment

Specify treatment:

Biopsy
Resection
Surgery:
Limited Resection; debulking
Other, specify
Other specify:

Cryotherapy (skin cancer)
Chemotherapy:
Other specify:

Hormonal Therapy
Interferon Alpha
Immunotherapy:

Prednisone
Rituximab
Other, specify

Other specify:

Radiation
Other treatment:
Best treatment response:
Progressive disease (PD)
Partial response (PR)
No treatment (NT)
Too early in treatment to evaluate (TE)
Stable disease (SD)
Complete response (CR)

Colo-rectal:

Dukes classification:

A
B
C
Unknown
Treatment Information:
Site(s) affected:
Primary organ

Regional lymph nodes

Adjacent organs

Distant metastases

Diagnosis date:

Immunosuppression Stopped
Immunosuppression:

Immunosuppression Reduced
No Immunosuppression Adjustment

Specify treatment:

Biopsy
Resection
Surgery:
Limited Resection; debulking
Other, specify
Other specify:

Cryotherapy (skin cancer)
Chemotherapy:
Other specify:

Hormonal Therapy
Immunotherapy:

Interferon Alpha
Prednisone

Rituximab
Other, specify
Other specify:

Radiation
Other treatment:
Best treatment response:
Progressive disease (PD)
Partial response (PR)
No treatment (NT)
Too early in treatment to evaluate (TE)
Stable disease (SD)
Complete response (CR)

Primary hepatic tumor:

Hepatocellular Carcinoma
Cholangiocarcinoma
Epithelioid-Hemangio-Endothelioma
Specify type:
Hepatoblastoma
Hemangiosarcoma
Other
Other specify:
Treatment Information:
Site(s) affected:
Primary organ

Regional lymph nodes

Adjacent organs

Distant metastases

Diagnosis date:

Immunosuppression Stopped
Immunosuppression:

Immunosuppression Reduced
No Immunosuppression Adjustment

Specify treatment:

Biopsy
Resection
Surgery:
Limited Resection; debulking
Other, specify
Other specify:

Cryotherapy (skin cancer)
Chemotherapy:
Other specify:

Hormonal Therapy
Interferon Alpha
Immunotherapy:

Prednisone
Rituximab
Other, specify

Other specify:

Radiation
Other treatment:
Best treatment response:
Progressive disease (PD)
Partial response (PR)
No treatment (NT)
Too early in treatment to evaluate (TE)

Stable disease (SD)
Complete response (CR)

Metastatic liver tumor:

Stomach Adenocarcinoma
Colon Adenocarcinoma
Breast Carcinoma
Specify original site:

Pancreas Carcinoma
Bronchial Carcinoma
Carcinoid (Neuroendocrine)
Other

Other specify:
Treatment Information:
Site(s) affected:
Primary organ

Regional lymph nodes

Adjacent organs

Distant metastases

Diagnosis date:

Immunosuppression Stopped
Immunosuppression:

Immunosuppression Reduced
No Immunosuppression Adjustment

Specify treatment:

Biopsy
Surgery:

Resection
Limited Resection; debulking

Other, specify
Other specify:

Cryotherapy (skin cancer)
Chemotherapy:
Other specify:

Hormonal Therapy
Interferon Alpha
Immunotherapy:

Prednisone
Rituximab
Other, specify

Other specify:

Radiation
Other treatment:
Best treatment response:
Progressive disease (PD)
Partial response (PR)
No treatment (NT)
Too early in treatment to evaluate (TE)
Stable disease (SD)
Complete response (CR)

Lung:

Small cell

Treatment Information:
Site(s) affected:
Primary organ

Regional lymph nodes

Non-small cell

Adjacent organs

Distant metastases

Diagnosis date:

Immunosuppression Stopped
Immunosuppression:

Immunosuppression Reduced
No Immunosuppression Adjustment

Specify treatment:

Biopsy
Resection
Surgery:
Limited Resection; debulking
Other, specify
Other specify:

Cryotherapy (skin cancer)
Chemotherapy:
Other specify:

Hormonal Therapy
Interferon Alpha
Immunotherapy:

Prednisone
Rituximab
Other, specify

Other specify:

Radiation
Other treatment:
Best treatment response:
Progressive disease (PD)
Partial response (PR)

No treatment (NT)
Too early in treatment to evaluate (TE)
Stable disease (SD)
Complete response (CR)

AML
ALL
MDS
Leukemia:
CML
CLL
Other
Treatment Information:
Site(s) affected:
Primary organ

Regional lymph nodes

Adjacent organs

Distant metastases

Diagnosis date:

Immunosuppression Stopped
Immunosuppression:

Immunosuppression Reduced
No Immunosuppression Adjustment

Specify treatment:

Biopsy
Resection
Surgery:
Limited Resection; debulking
Other, specify

Other specify:

Cryotherapy (skin cancer)
Chemotherapy:
Other specify:

Hormonal Therapy
Interferon Alpha
Immunotherapy:

Prednisone
Rituximab
Other, specify

Other specify:

Radiation
Other treatment:
Best treatment response:
Progressive disease (PD)
Partial response (PR)
No treatment (NT)
Too early in treatment to evaluate (TE)
Stable disease (SD)
Complete response (CR)

Sarcomas:
Site(s):
Specify type:
Other specify:
Treatment Information:
Site(s) affected:

Primary organ

Regional lymph nodes

Adjacent organs

Distant metastases

Diagnosis date:

Immunosuppression Stopped
Immunosuppression:

Immunosuppression Reduced
No Immunosuppression Adjustment

Specify treatment:

Biopsy
Resection
Surgery:
Limited Resection; debulking
Other, specify
Other specify:

Cryotherapy (skin cancer)
Chemotherapy:
Other specify:

Hormonal Therapy
Interferon Alpha
Immunotherapy:

Prednisone
Rituximab
Other, specify

Other specify:

Radiation
Other treatment:
Best treatment response:
Progressive disease (PD)

Partial response (PR)
No treatment (NT)
Too early in treatment to evaluate (TE)
Stable disease (SD)
Complete response (CR)

Other cancers:
Site(s):
Specify type:
Treatment Information:
Site(s) affected:
Primary organ

Regional lymph nodes

Adjacent organs

Distant metastases

Diagnosis date:

Immunosuppression Stopped
Immunosuppression:

Immunosuppression Reduced
No Immunosuppression Adjustment

Specify treatment:

Biopsy
Resection
Surgery:
Limited Resection; debulking
Other, specify
Other specify:

Cryotherapy (skin cancer)
Chemotherapy:

Other specify:

Hormonal Therapy
Interferon Alpha
Immunotherapy:

Prednisone
Rituximab
Other, specify

Other specify:

Radiation
Other treatment:
Best treatment response:
Progressive disease (PD)
Partial response (PR)
No treatment (NT)
Too early in treatment to evaluate (TE)
Stable disease (SD)
Complete response (CR)

Primary unknown:
Treatment Information:
Site(s) affected:
Primary organ

Regional lymph nodes

Adjacent organs

Distant metastases

Diagnosis date:

Immunosuppression Stopped
Immunosuppression:
Immunosuppression Reduced

No Immunosuppression Adjustment
Specify treatment:

Biopsy
Resection
Surgery:
Limited Resection; debulking
Other, specify
Other specify:

Cryotherapy (skin cancer)
Chemotherapy:
Other specify:

Hormonal Therapy
Interferon Alpha
Immunotherapy:

Prednisone
Rituximab
Other, specify

Other specify:

Radiation
Other treatment:
Best treatment response:
Progressive disease (PD)
Partial response (PR)
No treatment (NT)
Too early in treatment to evaluate (TE)
Stable disease (SD)
Complete response (CR)

Alive, Free of Tumor
Alive with Tumor
Outcome:
Dead, due to tumor
Dead, other causes

POST TX LYMPHOPROLIFERATIVE DISEASE AND LYMPHOMA
Diagnosis date:

Polymorphic Hyperplasia
Polymorphic PTLD(lymphoma)
Monomorphic PTLD(lymphoma)
Pathology:
Mutiple Myeloma, Plasmacytoma
Hodgkin's Disease
Other, Specify
Other Specify:

Monoclonal
Polyclonal
Clonality:
Oligoclonal
Unknown

B Cell
T Cell
Predominant cell type:
Other Specify
Unknown
Other specify:

Epstein-Barr virus (EBV) status of tumor:

Anatomy:

Lymph Nodes:

Gastrointestinal
Stomach
Small intestine
Colon

EBV positive

EBV negative

Single site

YES

Unknown

Multiple sites

NO

Allograft
Lung
Bone marrow
CNS
Liver

Other specify:

Ann Arbor stage:

I

II

III

IV

Unknown

PTLD Treatment
Abbreviations: PD-Progressive disease PR=Partial response SD-Stable disease CR-Complete response TE-Too early in
treatment to evaluate
1. Reduction/Cessation of immunosuppression:

Best response:

YES

PD

NO

SD

PR

CR

2. Surgery

Biopsy
Resection
Type:

Limited Resection; debulking
No Surgery
Other, specify

Other specify:

TE

Best response:

3. Anti-viral therapy:

PD

SD

YES

PR

CR

TE

PR

CR

TE

PR

CR

TE

NO

Acyclovir
Cytogam
Cytovene
Foscarnet
Drug 1:
Ganciclovir
IVIG
Valtrex
Other, specify
Other specify:

Best response:

PD

SD

Acyclovir
Cytogam
Cytovene
Foscarnet
Drug 2:
Ganciclovir
IVIG
Valtrex
Other, specify
Other specify:

Best response:

PD

SD

4. Chemotherapy:

YES

NO

Drug/Regimen 1:
Other specify:

Best response:

PD

SD

PR

CR

TE

PD

SD

PR

CR

TE

PR

CR

TE

CR

TE

Drug/Regimen 2:
Other specify:

Best response:

5. Radiation therapy:

Best Response:

6. Immunotherapy:

YES

PD

NO

SD

YES

NO

Hormonal Therapy
Interferon Alpha
Type:

Prednisone
Rituximab
Other, specify

Other specify:

Best response:

UNOS View Only

PD

SD

PR

Comments: