Download:
pdf |
pdfPre-Transplant Essential Data:
Disease Classification
CIBMTR Use Only
Sequence Number:
Date Received:
OMB No: 0915-0310
Expiration Date: 1/31/2020
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 0.85
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 10-33, Rockville, Maryland, 20857.
Expiration date:
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Event date: ___ ___ ___ ___ - ___ ___ - ___ ___
HCT type: (check all that apply)
Autologous
Allogeneic, unrelated
Allogeneic, related
Product type: (check all that apply)
Bone marrow
PBSC
Single cord blood unit
Multiple cord blood units
Other product
Specify:_____________________________________
CIBMTR Form 2402 revision 21 (page 1 of 77) Draft 34/2319/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Primary Disease for HCT
1.
Date of diagnosis of primary disease for HCT: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY
2.
MM
DD
What was the primary disease for which the HCT was performed?
Acute myelogenous leukemia (AML or ANLL) (10) - Go to question 3
Acute lymphoblastic leukemia (ALL) (20) - Go to question 85
Acute leukemia of ambiguous lineage and other myeloid neoplasms (80) - Go to question 146
Chronic myelogenous leukemia (CML) (40) - Go to question 150
Myelodysplastic (MDS) / myeloproliferative (MPN) diseases (50) (Please classify all preleukemias)
(If recipient has transformed to AML, indicate AML as the primary disease) - Go to question 161
Other leukemia (30) (includes CLL) - Go to question 255
Hodgkin lymphoma (150) - Go to question 262
Non-Hodgkin lymphoma (100) - Go to question 265
Multiple myeloma / plasma cell disorder (PCD) (170) - Go to question 271
Solid tumors (200) - Go to question 303
Severe aplastic anemia (300) (If the recipient developed MDS or AML, indicate MDS or AML as the primary disease)
- Go to question 305
Inherited abnormalities of erythrocyte differentiation or function (310) - Go to question 307
Disorders of the immune system (400) - Go to question 310
Inherited abnormalities of platelets (500) - Go to question 313
Inherited disorders of metabolism (520) - Go to question 315
Histiocytic disorders (570) - Go to question 317
Autoimmune diseases (600) - Go to question 319
Other disease (900) - Go to question 327
Acute Myelogenous Leukemia (AML)
3.
Specify the AML classification:
AML with recurrent genetic abnormalities
AML with t(9;11) (p22.3;q23.3); MLLT3-KMT2A (5)
AML with t(6;9) (p23;q34.1); DEK-NUP214 (6)
AML with inv(3) (q21.3;q26.2) or t(3;3) (q21.3;q26.2); GATA2, MECOM (7)
CIBMTR Form 2402 revision 21 (page 2 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
AML (megakaryoblastic) with t(1;22) (p13.3;q13.3); RBM15-MKL1 (8)
AML with t(8;21); (q22; q22.1); RUNX1-RUNX1T1 (281)
AML with inv(16)(p13.1;1q22) or t(16;16)(p13.1; q22); CBFB-MYH11 (282)
APL with PML-RARA (283)
AML with BCR-ABL1 (provisional entity) (3)
AML with mutated NPM1 (4)
AML with biallelic mutations of CEBPA (297)
AML with mutated RUNX1 (provisional entity) (298)
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)
AML, not otherwise specified
AML, minimally differentiated (286)
AML, not otherwise specified (280)
AML without maturation (287)
AML with maturation (288)
Acute myelomonocytic leukemia (289)
Acute monoblastic / acute monocytic leukemia (290)
Acute erythroid leukemia (erythroid / myeloid and pure erythroleukemia) (291)
Acute megakaryoblastic leukemia (292)
Acute basophilic leukemia (293)
Acute panmyelosis with myelofibrosis (294)
Myeloid sarcoma (295)
Myeloid leukemia associated with Down syndrome (299)
3.4. Did AML transform from MDS or MPN?
Yes – Also complete MDS Disease Classification questions
No
4.5. Is the disease (AML) therapy related?
Yes
No
Unknown
5.6. Did the recipient have a predisposing condition?
Yes - Go to question 7
No - Go to question 9
CIBMTR Form 2402 revision 21 (page 3 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Unknown - Go to question 9
6.7. Specify condition:
Bloom syndrome - Go to question 9
Down syndrome - Go to question 9
Fanconi anemia - Go to question 9
Neurofibromatosis type 1Dyskeratosis congenita - Go to question 9
Other condition - Go to question 8
7.8. Specify other condition: __________________________________________
CIBMTR Form 2402 revision 21 (page 4 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Labs at diagnosis
9.
Were cytogenetics tested (karyotyping or FISH)? (at diagnosis)
Yes - Go to question 10
No - Go to question 20
Unknown - Go to question 20
10.
Were cytogenetics tested via FISH?
Yes – Go to question 11
No - Go to question 15
11.
Results of tests:
Abnormalities identified – Go to question 12
No abnormalities - Go to question 15
Specify cytogenetic abnormalities identified at diagnosis:
12.
Specify number of distinct cytogenetic abnormalities:
One (1)
Three (3)
Two (2)
Four or more (4 or more)
13.
Specify abnormalities (check all that apply)
-5
-7
-17
-18
-X
-Y
+4
+8
+11
+13
+14
+21
+22
t(3;3)
t(6;9)
CIBMTR Form 2402 revision 21 (page 5 of 77) Draft 37/236/20176
Commented [EL1]: 1.Add some additional instructions
around how to answer these for patients that had a prior
fanconi, and give examples.
Commented [EL2]: 2.Same format as 2400 Q499
3.
4.Check to see what validations can be done.
Commented [EL3]: 5.For FA patients, clonal
abnormalities come and go. May have gotten several bone
marrow biopsies. Do we really want every abnormality
detected to be reported here?
6.
7.For this question – we’re looking to get abnormalities
detected since the transformation to AML.
8.
9.With how it’s worded, we may be capturing more than
needed for patients with a previous fanconi.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
t(8;21)
t(9;11)
t(9;22)
t(15;17) and variants
t(16;16)
del(3q) / 3q–
del(5q) / 5q–
del(7q) / 7q–
del(9q) / 9q–
del(11q) / 11q–
del(16q) / 16q–
del(17q) / 17q–
del(20q) / 20q–
del(21q) / 21q–
inv(3)
inv(16)
(11q23) any abnormality
12p any abnormality
Other abnormality - Go to question 14
14. Specify other abnormality: _____________________
15.
Were cyteogenetics tested via karyotyping?
Yes – Go to question 16
No - Go to question 20
16.
Results of tests:
Abnormalities identified – Go to question 17
No evaluable metaphases - Go to question 20
No abnormalities - Go to question 20
Specify cytogenetic abnormalities identified at diagnosis:
17.
Specify number of distinct cytogenetic abnormalities:
One (1)
CIBMTR Form 2402 revision 21 (page 6 of 77) Draft 37/236/20176
Commented [EL4]: 10.Add some additional instructions
around how to answer these for patients that had a prior
fanconi, and give examples.
Commented [EL5]: 11.Same format as 2400 Q499
12.
13.Check to see what validations can be done.
Commented [EL6]: 14.For FA patients, clonal
abnormalities come and go. May have gotten several bone
marrow biopsies. Do we really want every abnormality
detected to be reported here?
15.
16.For this question – we’re looking to get abnormalities
detected since the transformation to AML.
17.
18.With how it’s worded, we may be capturing more than
needed for patients with a previous fanconi.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Two (2)
Three (3)
Four or more (4 or more)
18.
Specify abnormalities: (check all that apply)
-5
-7
-17
-18
-X
-Y
+4
+8
+11
+13
+14
+21
+22
t(3;3)
t(6;9)
t(8;21)
t(9;11)
t(9;22)
t(15;17) and variants
t(16;16)
del(3q) / 3q–
del(5q) / 5q–
del(7q) / 7q–
del(9q) / 9q–
del(11q) / 11q–
del(16q) / 16q–
del(17q) / 17q–
del(20q) / 20q–
del(21q) / 21q–
inv(3)
inv(16)
(11q23) any abnormality
CIBMTR Form 2402 revision 21 (page 7 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
12p any abnormality
Other abnormality - Go to question 19
19. Specify other abnormality: _____________________
20. Were tests for molecular markers performed (e.g. PCR, NGS)? (at diagnosis)
Yes – Go to question 21
No – Go to question 31
Unknown – Go to question 31
Specify molecular markers identified at diagnosis:
21.
CEBPA
Positive – Go to question 22
Negative - Go to question 23
Not done - Go to question 23
23.
22.
Specify CEBPA mutation
Biallelic (homozygous)
Monoallelic (heterozygous)
Unknown
FLT3 – D835 point mutation
Positive
Negative
Not done
24.
FLT3 – ITD mutation
Positive
Negative
Not done
25.
IDH1
Positive
Negative
Not done
26.
IDH2
Positive
Negative
CIBMTR Form 2402 revision 21 (page 8 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
27.
Not done
KIT
Positive
Negative
Not done
28.
NPM1
Positive
Negative
Not done
29.
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Other molecular marker
Positive- Go to question 30
Negative- Go to question 30
Not done- Go to question 31
30.
Specify other molecular marker: _________________________________
Copy and complete questions 29-30 for multiple molecular markers
Labs at last evaluation prior to the start of the preparative regimen
31.
Were cytogenetics tested (karyotyping or FISH)? (at last evaluation)
Yes - Go to question 32
No - Go to question 42
Unknown - Go to question 42
32.
Were cyteogenetics tested via FISH?
Yes – Go to question 33
No - Go to question 37
33.
Results of tests:
Abnormalities identified – Go to question 34
No abnormalities - Go to question 37
Specify cytogenetic abnormalities identified at last evaluation prior to the start of the
preparative regimen:
34.
Specify number of distinct cytogenetic abnormalities:
One (1)
CIBMTR Form 2402 revision 21 (page 9 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Two (2)
Three (3)
Four or more (4 or more)
35.
Specify abnormalities (check all that apply)
-5
-7
-17
-18
-X
-Y
+4
+8
+11
+13
+14
+21
+22
t(3;3)
t(6;9)
t(8;21)
t(9;11)
t(9;22)
t(15;17) and variants
t(16;16)
del(3q) / 3q–
del(5q) / 5q–
del(7q) / 7q–
del(9q) / 9q–
del(11q) / 11q–
del(16q) / 16q–
del(17q) / 17q–
del(20q) / 20q–
del(21q) / 21q–
inv(3)
inv(16)
(11q23) any abnormality
CIBMTR Form 2402 revision 21 (page 10 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
12p any abnormality
Other abnormality - Go to question 36
36. Specify other abnormality: _____________________
37.
Were cyteogenetics tested via karyotyping?
Yes – Go to question 38
No - Go to question 42
38.
Results of tests:
Abnormalities identified – Go to question 39
No evaluable metaphases - Go to question 42
No abnormalities - Go to question 42
Specify cytogenetic abnormalities identified at last evaluation prior to the start of the
preparative regimen:
39.
Specify number of distinct cytogenetic abnormalities:
One (1)
Two (2)
Three (3)
Four or more (4 or more)
40.
Specify abnormalities (check all that apply)
-5
-7
-17
-18
-X
-Y
+4
+8
+11
+13
+14
+21
+22
CIBMTR Form 2402 revision 21 (page 11 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
t(3;3)
t(6;9)
t(8;21)
t(9;11)
t(9;22)
t(15;17) and variants
t(16;16)
del(3q) / 3q–
del(5q) / 5q–
del(7q) / 7q–
del(9q) / 9q–
del(11q) / 11q–
del(16q) / 16q–
del(17q) / 17q–
del(20q) / 20q–
del(21q) / 21q–
inv(3)
inv(16)
(11q23) any abnormality
12p any abnormality
Other abnormality - Go to question 41
41. Specify other abnormality: _____________________
42.
Were tests for molecular markers performed (e.g. PCR)? (at last evaluation)
Yes – Go to question 43
No – Go to question 55
Unknown – Go to question 55
Specify molecular markers identified at any time prior to the start of the preparative regimen:
43.
CEBPA
Positive – Go to question 44
Negative - Go to question 45
Not done - Go to question 45
44.
Specify CEBPA mutation
CIBMTR Form 2402 revision 21 (page 12 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
45.
Biallelic (homozygous)
Monoallelic (heterozygous)
Unknown
FLT3 – D835 point mutation
Positive
Negative
Not done
46.
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
FLT3 – ITD mutation
Positive - Go to question 47
Negative - Go to question 49
Not done - Go to question 49
47.
FLT3 – ITD allelic ratio
Known - Go to question 48
Unknown - Go to question 49
48. Specify FLT3 - ITD allelic ratio: ___ . ___
49.
IDH1
Positive
Negative
Not done
50.
IDH2
Positive
Negative
Not done
51.
KIT
Positive
Negative
Not done
52.
NPM1
Positive
Negative
CIBMTR Form 2402 revision 21 (page 13 of 77) Draft 37/236/20176
Commented [EL7]: 19.0.3-0.7
CIBMTR Center Number: ___ ___ ___ ___ ___
53.
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Not done
Other molecular marker
Positive- Go to question 54
Negative- Go to question 54
Not done- Go to question 55
54.
Specify other molecular marker: _________________________________
Copy and complete questions 53-54 to report multiple other molecular markers
Labs between diagnosis and last evaluation prior to the start of the preparative regimen
55.
Were cytogenetics tested (karyotyping or FISH)? (between diagnosis and last evaluation)
Yes - Go to question 56
No - Go to question 66
Unknown - Go to question 66
56.
Were cytogenetics tested via FISH?
Yes – Go to question 57
No - Go to question 61
57.
Results of tests:
Abnormalities identified – Go to question 58
No abnormalities - Go to question 61
Specify cytogenetic abnormalities identified between diagnosis and last evaluation:
58.
Specify number of distinct cytogenetic abnormalities:
One (1)
Two (2)
Three (3)
Four or more (4 or more)
59.
Specify abnormalities (check all that apply)
-5
-7
-17
-18
-X
CIBMTR Form 2402 revision 21 (page 14 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
-Y
+4
+8
+11
+13
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
+14
+21
+22
t(3;3)
t(6;9)
t(8;21)
t(9;11)
t(9;22)
t(15;17) and variants
t(16;16)
del(3q) / 3q–
del(5q) / 5q–
del(7q) / 7q–
del(9q) / 9q–
del(11q) / 11q–
del(16q) / 16q–
del(17q) / 17q–
del(20q) / 20q–
del(21q) / 21q–
inv(3)
inv(16)
(11q23) any abnormality
12p any abnormality
Other abnormality - Go to question 60
60. Specify other abnormality: _____________________
61.
Were cyteogenetics tested via karyotyping?
Yes – Go to question 62
No - Go to question 66
62.
Results of tests:
Abnormalities identified – Go to question 63
CIBMTR Form 2402 revision 21 (page 15 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
No evaluable metaphases - Go to question 66
No abnormalities - Go to question 66
Specify cytogenetic abnormalities identified between diagnosis and last evaluation:
63.
Specify number of distinct cytogenetic abnormalities:
One (1)
Three (3)
Two (2)
Four or more (4 or more)
64.
Specify abnormalities (check all that apply)
-5
-7
-17
-18
-X
-Y
+4
+8
+11
+13
+14
+21
+22
t(3;3)
t(6;9)
t(8;21)
t(9;11)
t(9;22)
t(15;17) and variants
t(16;16)
del(3q) / 3q–
del(5q) / 5q–
del(7q) / 7q–
del(9q) / 9q–
del(11q) / 11q–
del(16q) / 16q–
CIBMTR Form 2402 revision 21 (page 16 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
del(17q) / 17q–
del(20q) / 20q–
del(21q) / 21q–
inv(3)
inv(16)
(11q23) any abnormality
12p any abnormality
Other abnormality - Go to question 65
65. Specify other abnormality: _____________________
66.
Were tests for molecular markers performed (e.g. PCR)? (between diagnosis and last evaluation)
Yes – Go to question 67
No – Go to question 79
Unknown – Go to question 79
Specify molecular markers identified between diagnosis and last evaluation:
67.
CEBPA
Positive – Go to question 68
Negative - Go to question 69
Not done - Go to question 69
69.
68.
Specify CEBPA mutation
Biallelic (homozygous)
Monoallelic (heterozygous)
Unknown
FLT3 – D835 point mutation
Positive
Negative
Not done
70.
FLT3 – ITD mutation
Positive - Go to question 71
Negative - Go to question 73
Not done - Go to question 73
CIBMTR Form 2402 revision 21 (page 17 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
71.
FLT3 – ITD allelic ratio
Known - Go to question 72
Unknown - Go to question 73
72. Specify FLT3 - ITD allelic ratio: ___ . ___
73.
IDH1
Positive
Negative
Not done
74.
IDH2
Positive
Negative
Not done
75.
KIT
Positive
Negative
Not done
76.
NPM1
Positive
Negative
Not done
77.
Other molecular marker
Positive- Go to question 78
Negative- Go to question 78
Not done- Go to question 79
78.
Specify other molecular marker: _________________________________
Copy and complete questions 77-78 to report multiple other molecular markers
CNS Leukemia
CIBMTR Form 2402 revision 21 (page 18 of 77) Draft 37/236/20176
Commented [EL8]: 20.0.3-0.7
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
79.
Did the recipient have central nervous system leukemia at any time prior to the start of the preparative regimen /
infusion?
Yes
No
Unknown
8. ________________________________________________________________________________________ Were
cytogenetics tested (karyotyping or FISH)?
3. ________________________________________________________________________________________
Yes - Go to question 10
4. ________________________________________________________________________________________
No
- Go to question 47
5. ________________________________________________________________________________________
Unknown - Go to question 47
9. ________________________________________________________________________________________ Result
s of tests:
6. ________________________________________________________________________________________
__________________________________________________________________________________________
Abnormalities identified – Go to question 11
7. ________________________________________________________________________________________
__________________________________________________________________________________________ No
evaluable metaphases - Go to question 47
8. ________________________________________________________________________________________
__________________________________________________________________________________________ No
abnormalities - Go to question 47
9. ________________________________________________________________________________________ Specif
y cytogenetic abnormalities identified at any time prior to the start of the preparative regimen:
10. _______________________________________________________________________________________ Mono
somy
10. _______________________________________________________________________________________ –5
11. _______________________________________________________________________________________
Yes
CIBMTR Form 2402 revision 21 (page 19 of 77) Draft 37/236/20176
Commented [EL9]: 21.Need to clarify that this is
negative lp. If not tested, need to mark UK, Not tested.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
12. _______________________________________________________________________________________
No
11. _______________________________________________________________________________________ –7
13. _______________________________________________________________________________________
Yes
14. _______________________________________________________________________________________
No
12. _______________________________________________________________________________________ –17
15. _______________________________________________________________________________________
Yes
16. _______________________________________________________________________________________
No
13. _______________________________________________________________________________________ –18
17. _______________________________________________________________________________________
Yes
18. _______________________________________________________________________________________
No
14. _______________________________________________________________________________________ –X
19. _______________________________________________________________________________________
Yes
20. _______________________________________________________________________________________
No
15. _______________________________________________________________________________________ –Y
CIBMTR Form 2402 revision 21 (page 20 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
21. _______________________________________________________________________________________
Yes
22. _______________________________________________________________________________________
No
23. _______________________________________________________________________________________ Triso
my
16. _______________________________________________________________________________________ +4
24. _______________________________________________________________________________________
Yes
25. _______________________________________________________________________________________
No
17. _______________________________________________________________________________________ +8
26. _______________________________________________________________________________________
Yes
27. _______________________________________________________________________________________
No
18. _______________________________________________________________________________________ +11
28. _______________________________________________________________________________________
Yes
29. _______________________________________________________________________________________
No
19. _______________________________________________________________________________________ +13
30. _______________________________________________________________________________________
Yes
CIBMTR Form 2402 revision 21 (page 21 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
31. _______________________________________________________________________________________
No
20. _______________________________________________________________________________________ +14
32. _______________________________________________________________________________________
Yes
33. _______________________________________________________________________________________
No
21. _______________________________________________________________________________________ +21
34. _______________________________________________________________________________________
Yes
35. _______________________________________________________________________________________
No
22. _______________________________________________________________________________________ +22
36. _______________________________________________________________________________________
Yes
37. _______________________________________________________________________________________
No
38. _______________________________________________________________________________________ Transl
ocation
23. _______________________________________________________________________________________ t(3;3)
39. _______________________________________________________________________________________
Yes
40. _______________________________________________________________________________________
No
24. _______________________________________________________________________________________ t(6;9)
CIBMTR Form 2402 revision 21 (page 22 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
41. _______________________________________________________________________________________
Yes
42. _______________________________________________________________________________________
No
25. _______________________________________________________________________________________ t(8;21)
43. _______________________________________________________________________________________
Yes
44. _______________________________________________________________________________________
No
26. _______________________________________________________________________________________ t(9;11)
45. _______________________________________________________________________________________
Yes
46. _______________________________________________________________________________________
No
27. _______________________________________________________________________________________ t(9;22)
47. _______________________________________________________________________________________
Yes
48. _______________________________________________________________________________________
No
28. _______________________________________________________________________________________ t(15;1
7) and variants
49. _______________________________________________________________________________________
Yes
50. _______________________________________________________________________________________
No
CIBMTR Form 2402 revision 21 (page 23 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
29. _______________________________________________________________________________________ t(16;1
6)
51. _______________________________________________________________________________________
Yes
52. _______________________________________________________________________________________
No
53. _______________________________________________________________________________________ Deleti
on
30. _______________________________________________________________________________________ del(3q
) / 3q–
54. _______________________________________________________________________________________
Yes
55. _______________________________________________________________________________________
No
31. _______________________________________________________________________________________ del(5q
) / 5q–
56. _______________________________________________________________________________________
Yes
57. _______________________________________________________________________________________
No
32. _______________________________________________________________________________________ del(7q
) / 7q–
58. _______________________________________________________________________________________
Yes
59. _______________________________________________________________________________________
No
CIBMTR Form 2402 revision 21 (page 24 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
33. _______________________________________________________________________________________ del(9q
) / 9q–
60. _______________________________________________________________________________________
Yes
61. _______________________________________________________________________________________
No
34. _______________________________________________________________________________________ del(11
q) / 11q–
62. _______________________________________________________________________________________
Yes
63. _______________________________________________________________________________________
No
35. _______________________________________________________________________________________ del(16
q) / 16q–
64. _______________________________________________________________________________________
Yes
65. _______________________________________________________________________________________
No
36. _______________________________________________________________________________________ del(17
q) / 17q–
66. _______________________________________________________________________________________
Yes
67. _______________________________________________________________________________________
No
37. _______________________________________________________________________________________ del(20
q) / 20q–
CIBMTR Form 2402 revision 21 (page 25 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
68. _______________________________________________________________________________________
Yes
69. _______________________________________________________________________________________
No
38. _______________________________________________________________________________________ del(21
q) / 21q–
70. _______________________________________________________________________________________
Yes
71. _______________________________________________________________________________________
No
72. _______________________________________________________________________________________ Invers
ion
39. _______________________________________________________________________________________ inv(3)
73. _______________________________________________________________________________________
Yes
74. _______________________________________________________________________________________
No
40. _______________________________________________________________________________________ inv(16
)
75. _______________________________________________________________________________________
Yes
76. _______________________________________________________________________________________
No
77. _______________________________________________________________________________________ Other
41. _______________________________________________________________________________________
(11q23) any abnormality
CIBMTR Form 2402 revision 21 (page 26 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
78. _______________________________________________________________________________________
Yes
79. _______________________________________________________________________________________
No
42. _______________________________________________________________________________________ 12p
any abnormality
80. _______________________________________________________________________________________
Yes
81. _______________________________________________________________________________________
No
43. _______________________________________________________________________________________ Compl
ex - ≥ 3 distinct abnormalities
82. _______________________________________________________________________________________
Yes
83. _______________________________________________________________________________________
No
44. _______________________________________________________________________________________ Other
abnormality
84. _______________________________________________________________________________________
Yes - Go to question 46
85. _______________________________________________________________________________________
No - Go to question 47
45. _______________________________________________________________________________________ Specif
y other abnormality: __________________________________
46. _______________________________________________________________________________________ Were
tests for molecular markers performed (e.g. PCR)?
Yes – Go to question 48
No – Go to question 57
CIBMTR Form 2402 revision 21 (page 27 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Unknown – Go to question 57
Specify molecular markers identified at any time prior to the start of the preparative regimen:
47.
CEBPA
Positive
Negative
Not done
48.
FLT3 – D835 point mutation
Positive
Negative
Not done
49.
FLT3 – ITD mutation
Positive
Negative
Not done
50.
IDH1
Positive
Negative
Not done
51.
IDH2
Positive
Negative
Not done
52.
KIT
Positive
Negative
Not done
53.
NPM1
Positive
Negative
Not done
CIBMTR Form 2402 revision 21 (page 28 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
54. _______________________________________________________________________________________ Other
molecular marker
Positive- Go to question 56
Negative- Go to question 56
Not done- Go to question 57
55.
Specify other molecular marker: _________________________________
Status at transplantation:
56.80. ___________________________________________________________________________________ What
was the disease status (based on hematological test results)?
Primary induction failure – Go to question 84
1st complete remission (no previous bone marrow or extramedullary relapse) (include CRi and CRp)– Go to
2nd complete remission – Go to question 81
question 81
≥ 3rd complete remission – Go to question 81
1st relapse – Go to question 83
2nd relapse – Go to question 83
≥ 3rd relapse – Go to question 83
No treatment – Go to question 84
57.81. How many cycles of induction therapy were required to achieve 1st complete remission? (e CRincludes
CRi, CRp)?
1
2
≥ 3
58.
Was the recipient in molecular remission?
3.
Yes
4.
No
5.
Unknown
6.
Not applicable
59.82. Was the recipient in remission by flow cytometry?
Yes – Go to question 84
No – Go to question 84
Unknown – Go to question 84
Not applicable – Go to question 84
CIBMTR Form 2402 revision 21 (page 29 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
60.
Was the recipient in cytogenetic remission?
7.
Yes – Go to question 63
8.
No – Go to question 63
9.
Unknown – Go to question 63
10.
Not applicable– Go to question 63
61.83. Date of most recent relapse: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY
MM
DD
62.84. ___________________________________________________________________________________ Date
assessed: ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to signature line
YYYY
MM
DD
Acute Lymphoblastic Leukemia (ALL)
86.85. Specify ALL classification:
B-lymphoblastic leukemia / lymphoma
B-lymphoblastic leukemia / lymphoma, NOS (B-cell ALL, NOS) (191)
B-lymphoblastic leukemia / lymphoma with t(9;22)(q34.1;q11.2); BCR-ABL1 (192)
B-lymphoblastic leukemia / lymphoma with t(v;11q23.3); KMT2A rearranged (193)
B-lymphoblastic leukemia / lymphoma with t(1;19)(q23;p13.3); TCF3-PBX1 (194)
B-lymphoblastic leukemia / lymphoma with t(12;21) (p13.2;q22.1); ETV6-RUNX1 (195)
B-lymphoblastic leukemia / lymphoma with t(5;14) (q31.1;q32.3); IL3-IGH (81)
B-lymphoblastic leukemia / lymphoma with Hyperdiploidy (51-65 chromosomes) (82)
B-lymphoblastic leukemia / lymphoma with Hypodiploidy (<45 chromosomes) (83)
B-lymphoblastic leukemia / lymphoma, BCR-ABL1-like (provisional entity) (94)
B-lymphoblastic leukemia / lymphoma, with iAMP21 (provisional entity) (95)
T-cell lymphoblastic leukemia / lymphoma
Early T-cell precursor lymphoblastic leukemia (provisional entity) (96)
Natural killer (NK)- cell lymphoblastic leukemia / lymphoma (provisional entity) (97)
86.
Did the recipient have a predisposing condition?
CIBMTR Form 2402 revision 21 (page 30 of 77) Draft 37/236/20176
Commented [EL10]: 22. Divider for paper form only.
Doesn’t need to be in FDM
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Yes - Go to question 66
No - Go to question 68
Unknown - Go to question 68
87. Specify condition:
Aplastic anemia - Go to question 68
Bloom syndrome - Go to question 68
Down syndrome - Go to question 68
Fanconi anemia - Go to question 68
Other condition - Go to question 67
87.88.
Also complete CIBMTR Form 2028 — APL
Also complete CIBMTR Form 2029 — FAN
Specify other condition: _______________________________________________________
88.89. 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
Laboratory studies at diagnosis:
90.
Were cytogenetics tested (karyotyping or FISH)? (at diagnosis)
Yes - Go to question 70
No - Go to question 81
Unknown - Go to question 81
91.
Were cytogenetics tested via FISH? (at diagnosis)
Yes - Go to question 71
No - Go to question 75
92. Results of tests: (at diagnosis)
Abnormalities identified - Go to question 72
No abnormalities - Go to question 75
Specify cytogenetic abnormalities identified:
93. Specify number of distinct cytogenetic abnormalities:
One (1)
Two (2)
Three (3)
Four or more (4 or more)
CIBMTR Form 2402 revision 21 (page 31 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
94. Specify abnormalities: (check all that apply)
–7
+4
+8
+21
+17
t(1;19)
t(2;8)
t(5;14)
t(4;11)
t(8;14)
t(8;22)
t(10;14)
t(11;14)
del(6q) / 6q–
del(12p) / 12p–
add(14q)
9p any abnormality
Hyperdiploid (> 50)
Hypodiploid (< 45)
t(9;22)
t(12;21)
del(9p) / 9p–
(11q23) any abnormality
12p any abnormality
Other abnormality – Go to question 74
95. Specify other abnormality: ________________________________________________
96. Were cytogenetics tested via karyotyping? (at diagnosis)
Yes - Go to question 76
No - Go to question 80
97.
Results of tests: (at diagnosis)
Abnormalities identified - Go to question 77
No evaluable metaphases - Go to question 80
No abnormalities - Go to question 80
CIBMTR Form 2402 revision 21 (page 32 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Specify cytogenetic abnormalities identified:
98.
Specify number of distinct cytogenetic abnormalities:
One (1)
Two (2)
Three (3)
Four or more (4 or more)
99.
Specify abnormalities: (check all that apply)
–7
+4
+8
+17
+21
t(1;19)
t(2;8)
t(4;11)
t(5;14)
t(8;14)
t(8;22)
t(9;22)
t(10;14)
t(11;14)
t(12;21)
del(6q) / 6q–
del(9p) / 9p–
del(12p) / 12p–
add(14q)
(11q23) any abnormality
9p any abnormality
12p any abnormality
Hyperdiploid (> 50)
Hypodiploid (< 45)
Other abnormality – Go to question 79
89.100. Specify other abnormality: _________________________
90.
Were cytogenetics tested (karyotyping or FISH)?
Yes - Go to question 67
CIBMTR Form 2402 revision 21 (page 33 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
No - Go to question 95
Unknown - Go to question 95
91.
Results of tests:
Abnormalities identified – Go to question 68
No evaluable metaphases - Go to question 95
No abnormalities - Go to question 95
Specify cytogenetic abnormalities identified at any time prior to the start of the preparative
regimen:
Monosomy
92.
–7
Yes
No
Trisomy
93.
+4
Yes
No
94.
+8
Yes
No
95.
+17
Yes
No
96.
+21
Yes
No
Translocation
97.
t(1;19)
Yes
No
CIBMTR Form 2402 revision 21 (page 34 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
98.
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
t(2;8)
Yes
No
99.
t(4;11)
Yes
No
100.
t(5;14)
Yes
No
101.
t(8;14)
Yes
No
102.
t(8;22)
Yes
No
103.
t(9;22)
Yes
No
104.
t(10;14)
Yes
No
105.
t(11;14)
Yes
No
106.
t(12;21)
Yes
No
Deletion
107.
del(6q) / 6q–
Yes
CIBMTR Form 2402 revision 21 (page 35 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
No
108.
del(9p) / 9p–
Yes
No
109.
del(12p) / 12p–
Yes
No
Addition
110.
add(14q)
Yes
No
Other
111.
(11q23) any abnormality
Yes
No
112.
9p any abnormality
Yes
No
113.
12p any abnormality
Yes
No
114.
Hyperdiploid (> 50)
Yes
No
115.
Hypodiploid (< 46)
Yes
No
116.
Complex - ≥3 distinct abnormalities
Yes
CIBMTR Form 2402 revision 21 (page 36 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
No
117.
Other abnormality
Yes - Go to question 94
No - Go to question 95
118.
Specify other abnormality: ___________________________
119.101. __________________________________________________________________________________ Were
tests for molecular markers performed (e.g. PCR)? (at diagnosis)
Yes – Go to question 96
No – Go to question 100
Unknown – Go to question 100
Specify molecular markers identified at diagnosisany time prior to the start of the preparative regimen:
120.102. _____________________________________________________________________________ BCR /
ABL
Positive
Negative
Not done
121.103. _____________________________________________________________________________ TELAML / AML1
Positive
Negative
Not done
122.104. _____________________________________________________________________________ Other
molecular marker
Positive – Go to question 99
Negative – Go to question 99
Not done – Go to question 100
123.105.________________________________________________________________________ Specif
y other molecular marker: _________________________________________________________________
Copy and complete questions 98-99 for additional molecular markers
Laboratory studies at last evaluation prior to the start of the preparative regimen:
106.
Were cytogenetics tested (karyotyping or FISH)? (at last evaluation prior to the start of the preparative regimen)
CIBMTR Form 2402 revision 21 (page 37 of 77) Draft 37/236/20176
Commented [EL11]: 23.Max of 3
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Yes - Go to question 86
No - Go to question 97
Unknown - Go to question 97
107.
Were cytogenetics tested via FISH?
Yes - Go to question 87
No - Go to question 91
108. Results of tests:
Abnormalities identified - Go to question 88
No abnormalities - Go to question 91
Specify cytogenetic abnormalities identified at last evaluation prior to the start of the
preparative regimen:
109.
Specify number of distinct cytogenetic abnormalities:
One (1)
Two (2)
Three (3)
Four or more (4 or more)
110.
Specify abnormalities: (check all that apply)
–7
+4
+8
+17
+21
t(2;8)
t(1;19)
t(4;11)
t(5;14)
t(8;22)
t(8;14)
t(9;22)
t(10;14)
t(11;14)
del(6q) / 6q–
t(12;21)
del(9p) / 9p–
CIBMTR Form 2402 revision 21 (page 38 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
del(12p) / 12p–
add(14q)
(11q23) any abnormality
9p any abnormality
Hyperdiploid (> 50)
Hypodiploid (< 45)
12p any abnormality
Other abnormality – Go to question 90
111.
112.
Specify other abnormality: ________________________________________
Were cytogenetics tested via karyotyping? (at last evaluation prior to the start of the preparative regimen)
Yes - Go to question 92
No - Go to question 97
113.
Results of tests:
Abnormalities identified - Go to question 93
No evaluable metaphases - Go to question 97
No abnormalities - Go to question 97
Specify cytogenetic abnormalities identified at last evaluation prior to the start of the
preparative regimen:
114.
Specify number of distinct cytogenetic abnormalities:
One (1)
Two (2)
Three (3)
Four or more (4 or more)
115.
Specify abnormalities: (check all that apply)
–7
+4
+8
+17
+21
t(1;19)
t(2;8)
t(4;11)
t(5;14)
CIBMTR Form 2402 revision 21 (page 39 of 77) Draft 37/236/20176
Commented [EL12]: 24. Need to look at this for
analysis.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
t(8;14)
t(8;22)
t(9;22)
t(10;14)
t(11;14)
t(12;21)
del(6q) / 6q–
del(9p) / 9p–
del(12p) / 12p–
add(14q)
(11q23) any abnormality
9p any abnormality
12p any abnormality
Hyperdiploid (> 50)
Hypodiploid (< 45)
Other abnormality – Go to question 95
116.
117.
Specify other abnormality: __________________________________________
Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)
Yes
No
118.
Were tests for molecular markers performed (e.g. PCR)? (at last evaluation prior to the start of the preparative
regimen)
Yes – Go to question 98
No – Go to question 102
Unknown – Go to question 102
Specify molecular markers identified at last evaluation prior to the start of the preparative regimen:
119.
BCR / ABL
Positive
Negative
Not done
120.
TEL-AML / AML1
Positive
Negative
CIBMTR Form 2402 revision 21 (page 40 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
121.
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Not done
Other molecular marker
Positive – Go to question 102
Negative – Go to question 102
Not done – Go to question 103
122.
Specify other molecular marker: ______________________________________________
Copy and complete questions 100-101 for additional molecular markers
Laboratory studies between diagnosis last evaluation prior to the start of the preparative regimen:
123.
Were cytogenetics tested (karyotyping or FISH)? (between diagnosis and last evaluation)
Yes - Go to question 103
No - Go to question 114
Unknown - Go to question 114
124.
Were cytogenetics tested via FISH? (between diagnosis and the last evaluation)
Yes - Go to question 104
No - Go to question 108
125.
Results of tests: (between diagnosis and the last evaluation)
Abnormalities identified - Go to question 105
No abnormalities - Go to question 108
Specify cytogenetic abnormalities identified at diagnosis:
126.
Specify number of distinct cytogenetic abnormalities:
One (1)
Two (2)
Three (3)
Four or more (4 or more)
127.
Specify abnormalities: (check all that apply)
–7
+4
+8
+21
+17
CIBMTR Form 2402 revision 21 (page 41 of 77) Draft 37/236/20176
Commented [EL13]: 25.Max of 3
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
t(1;19)
t(2;8)
t(4;11)
t(5;14)
t(8;22)
t(8;14)
t(9;22)
t(10;14)
t(11;14)
del(6q) / 6q–
del(12p) / 12p–
add(14q)
t(12;21)
del(9p) / 9p–
(11q23) any abnormality
9p any abnormality
Hyperdiploid (> 50)
Hypodiploid (< 45)
12p any abnormality
Other abnormality – Go to question 107
128.
Specify other abnormality: ___________________________________________
129. Were cytogenetics tested via karyotyping? (between diagnosis and the last evaluation)
Yes - Go to question 109
No - Go to question 114
130. Results of tests: (between diagnosis and the last evaluation)
Abnormalities identified - Go to question 110
No evaluable metaphases - Go to question 114
No abnormalities - Go to question 114
Specify cytogenetic abnormalities identified at diagnosis:
131.
Specify number of distinct cytogenetic abnormalities:
One (1)
Two (2)
Three (3)
CIBMTR Form 2402 revision 21 (page 42 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Four or more (4 or more)
132.
Specify abnormalities: (check all that apply)
–7
+4
+8
+17
+21
t(1;19)
t(2;8)
t(4;11)
t(5;14)
t(8;14)
t(8;22)
t(9;22)
t(10;14)
t(11;14)
t(12;21)
del(6q) / 6q–
del(9p) / 9p–
del(12p) / 12p–
add(14q)
(11q23) any abnormality
9p any abnormality
12p any abnormality
Hyperdiploid (> 50)
Hypodiploid (< 45)
Other abnormality – Go to question 112
133.
Specify other abnormality: __________________________________________
134. Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)
Yes
No
135.
Were tests for molecular markers performed (e.g. PCR)? (between diagnosis and last evaluation prior to the
start of the preparative regimen)
Yes – Go to question 115
CIBMTR Form 2402 revision 21 (page 43 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
No – Go to question 119
Unknown – Go to question 119
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Specify molecular markers identified between diagnosis last evaluation prior to the start of the
preparative regimen:
136.
BCR / ABL
Positive
Negative
Not done
137.
TEL-AML / AML1
Positive
Negative
Not done
138.
Other molecular marker
Positive – Go to question 118
Negative – Go to question 118
Not done – Go to question 119
139.
Specify other molecular marker: ______________________________________________
Copy and complete questions 117-118 for additional molecular markers
CNS Leukemia
140. Did the recipient have central nervous system leukemia at any time prior to the start of the preparative regimen?
Yes
No
Unknown
Status at transplantation:
CIBMTR Form 2402 revision 21 (page 44 of 77) Draft 37/236/20176
Commented [EL14]: 26.Max of 3
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
124.141. ___________________________________________________________________________________ What
was the disease status (based on hematological test results)?
Primary induction failure – Go to question 106
1st complete remission (no previous marrow or extramedullary relapse) – Go to question 101
2nd complete remission – Go to question 101
≥ 3rd complete remission – Go to question 101
1st relapse – Go to question 105
2nd relapse – Go to question 105
≥ 3rd relapse – Go to question 105
No treatment – Go to question 106
125.142. _____________________________________________________________________________ How
many cycles of induction therapy were required to achieve 1st complete remissionCR?
1
2
≥ 3
126.
Was the recipient in molecular remission?
Yes
No
Unknown
Not applicable
127.143. _____________________________________________________________________________ Was
the recipient in remission by flow cytometry?
Yes
No
Unknown
Not applicable
128.
Was the recipient in cytogenetic remission?
Yes – Go to question 106
No – Go to question 106
Unknown – Go to question 106
Not applicable – Go to question 106
129.144. _____________________________________________________________________________ Date
of most recent relapse: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY
CIBMTR Form 2402 revision 21 (page 45 of 77) Draft 37/236/20176
MM
DD
CIBMTR Center Number: ___ ___ ___ ___ ___
130.145.
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Date assessed: ________ ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to signature line
YYYY
MM
DD
Acute Leukemias of Ambiguous Lineage and Other Myeloid Neoplasms
1.
Specify acute leukemias of ambiguous lineage and other myeloid neoplasm classification:
Blastic plasmacytoid dendritic cell neoplasm (296)– Go to question 109
Acute undifferentiated leukemia (31) – Go to question 109
Mixed phenotype acute leukemia (MPAL) with t(9;22)(q34.1;q11.2); BCR-ABL1 (84) – Go to question 109
Mixed phenotype acute leukemia with t(v; 11q23.3); KMT2A rearranged (85) – Go to question 109
Mixed phenotype acute leukemia, B/myeloid, NOS (86) – Go to question 109
Mixed phenotype acute leukemia, T/myeloid, NOS (87) – Go to question 109
Other acute leukemia of ambiguous lineage or myeloid neoplasm (88) - Go to question 108
2.
Specify other acute leukemia of ambiguous lineage or myeloid neoplasm: ___________________
Status at transplantation:
3.
What was the disease status (based on hematological 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
4.
Date assessed: ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to signature line
YYYY
MM
CIBMTR Form 2402 revision 21 (page 46 of 77) Draft 37/236/20176
DD
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Chronic Myelogenous Leukemia (CML)
5.
Was therapy given prior to this HCT?
Yes - Go to questions 112
No - Go to question 118
6.
Combination chemotherapy
Yes
No
7.
Hydroxyurea (Droxia, Hydrea)
Yes
No
8.
Tyrosine kinase inhibitor (e.g.imatinib mesylate, dasatinib, nilotinib)
Yes
No
9.
Interferon-α (Intron, Roferon) (includes PEG)
Yes
No
10.
Other therapy
Yes - Go to question 117
No - Go to question 118
11.
12.
Specify other therapy: ______________________________________
What was the disease status?
Complete hematologic response (CHR) - Go to questions 119
Chronic phase – Go to question 119
Accelerated phase - Go to question 120
CIBMTR Form 2402 revision 21 (page 47 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Blast phase - Go to question 120
13.
Specify level of response
No cytogenetic response (No CyR)
Minimal cytogenetic response
Minor cytogenetic response
Partial cytogenetic response (PCyR)
Complete cytogenetic response (CCyR)
Major molecular remission (MMR)
Complete molecular remission (CMR)
14.
Number
1st
2nd
3rd or higher
15.
Date assessed: ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to signature line
YYYY
MM
DD
Myelodysplastic (MDS) / Myeloproliferative (MPN) Diseases
16. What was the MDS / MPN subtype at diagnosis? – If transformed to AML, indicate AML as primary disease;
also complete AML Disease Classification questions
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 cytopenia with multilineage dysplasia (RCMD) (64)
Childhood myelodysplastic syndrome (Refractory cytopenia of childhood (RCC)) (68)
Myelodysplastic syndrome with isolated del(5q) (5q– syndrome) (66)
Chronic neutrophilic leukemia (165)
Essential thrombocythemia (includes primary thrombocytosis, idiopathic thrombocytosis, hemorrhagic
Refractory anemia with excess blasts-2 (RAEB-2) (62)
Myelodysplastic syndrome (MDS), unclassifiable (50)
Chronic eosinophilic leukemia, NOS (166)
thrombocythemia) (58)
CIBMTR Form 2402 revision 21 (page 48 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Polycythemia vera (PCV) (57)
Primary myelofibrosis (includes chronic idiopathic myelofibrosis (CIMF), angiogenic myeloid metaplasia
(AMM), myelofibrosis/sclerosis with myeloid metaplasia (MMM), idiopathic myelofibrosis) (167)
Myeloproliferative neoplasm (MPN), unclassifiable (60)
Chronic myelomonocytic leukemia (CMMoL) (54)
Juvenile myelomonocytic leukemia (JMML/JCML) (no evidence of Ph1 or BCR/ABL) (36) – Go to question
167
Atypical chronic myeloid leukemia, Ph-/bcr/abl- {CML, NOS} (45) - Go to question 220
Atypical chronic myeloid leukemia, Ph-/bcr unknown {CML, NOS} (46) - Go to question 220
Atypical chronic myeloid leukemia, Ph unknown/bcr- {CML, NOS} (48) - Go to question 220
Atypical chronic myeloid leukemia, Ph unknown/bcr unknown {CML, NOS} (49) - Go to question 220
Myelodysplastic / myeloproliferative neoplasm, unclassifiable (69)
17.
Was the disease (MDS/MPN) therapy related?
Yes
No
Unknown
18.
Did the recipient have a predisposing condition?
Yes – Go to question 125
No – Go to question 127
Unknown – Go to question 127
19.
Specify condition:
Aplastic anemia – Go to question 127
Bloom syndrome – Go to question 127
Down syndrome – Go to question 127
Fanconi anemia – – Go to question 127
Other condition – Go to question 126
20.
Specify other condition: ____________________________________________________
Laboratory studies at diagnosis of MDS:
21.
WBC
Known
Unknown
22.
___ ___ ___ ___ ___ ___ ● ___ x 109/L (x 103/mm3)
CIBMTR Form 2402 revision 21 (page 49 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
x 106/L
23.
Hemoglobin
Known
Unknown
g/dL
24.
___ ___ ___ ___ ● ___ ___
g/L
mmol/L
25.
Was RBC transfused ≤ 30 days before date of test?
Yes
No
26.
Platelets
Known
Unknown
27.
___ ___ ___ ___ ___ ___ ___ x 109/L (x 103/mm3)
x 106/L
28.
Were platelets transfused ≤ 7 days before date of test?
Yes
No
29.
Neutrophils
Known
Unknown
30.
31.
___ ___%
Blasts in bone marrow
Known
Unknown
32.
33.
___ ___ ___ %
Were cytogenetics tested (karyotyping or FISH)?
Yes – Go to question 140
No – Go to question 167
CIBMTR Form 2402 revision 21 (page 50 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Unknown – Go to question 167
34.
Results of tests:
Abnormalities identified – Go to question 141
No evaluable metaphases – Go to question 167
No abnormalities – Go to question 167
Specify abnormalities identified at diagnosis:
35.
Specify number of distinct cytogenetic abnormalities:
One (1)
Two (2)
Three (3)
Four or more (4 or more)
Monosomy
36.
–5
Yes
No
37. –7
Yes
No
38. –13
Yes
No
39. –20
Yes
No
40. –Y
Yes
No
Trisomy
CIBMTR Form 2402 revision 21 (page 51 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
41. +8
Yes
No
42. +19
Yes
No
Translocation
43. t(1;3)
Yes
No
44. t(2;11)
Yes
No
45. t(3;3)
Yes
No
46. t(3;21)
Yes
No
47. t(6;9)
Yes
No
48. t(11;16)
Yes
No
Deletion
49. del(3q) / 3q-
Yes
No
50. del(5q) / 5qCIBMTR Form 2402 revision 21 (page 52 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Yes –
No
51. del(7q) / 7q-
Yes
No
52. del(9q) / 9q-
Yes
No
53. del(11q) / 11q-
Yes
No
54. del(12p) / 12p-
Yes
No
55. del(13q) / 13q-
Yes
No
56. del(20q) / 20q-
Yes
No
Inversion
57. inv(3)
Yes
No
Other
58. i17q
Yes
No
59. Other abnormality
CIBMTR Form 2402 revision 21 (page 53 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Yes – Go to question 166
No – Go to question 167
60.
61.
Specify other abnormality: ______________________________________________
Did the recipient progress or transform to a different MDS / MPN subtype between diagnosis and the start of the
preparative regimen?
Yes – Go to question 168
No – Go to question 171
62.
Specify the MDS / MPN subtype after transformation:
Refractory cytopenia with unilineage dysplasia (RCUD) (includes refractory anemia (RA)) (51) – Go to
question 169
Refractory anemia with ringed sideroblasts (RARS) (55) – Go to question 169
Refractory anemia with excess blasts-1 (RAEB-1) (61) – Go to question 169
Refractory anemia with excess blasts-2 (RAEB-2) (62) – Go to question 169
Refractory cytopenia with multilineage dysplasia (RCMD) (64) – Go to question 169
Childhood myelodysplastic syndrome (Refractory cytopenia of childhood (RCC)) (68) – Go to
question 169
Myelodysplastic syndrome with isolated del(5q) (5q– syndrome) (66) – Go to question 169
Myelodysplastic syndrome (MDS), unclassifiable (50) – Go to question 169
Chronic neutrophilic leukemia (165) – Go to question 169
Chronic eosinophilic leukemia, NOS (166) – Go to question 169
Essential thrombocythemia (includes primary thrombocytosis, idiopathic thrombocytosis, hemorrhagic
thrombocythemia) (58) – Go to question 169
Polycythemia vera (PCV) (57) – Go to question 169
Primary myelofibrosis (includes chronic idiopathic myelofibrosis (CIMF), angiogenic myeloid
metaplasia (AMM), myelofibrosis/sclerosis with myeloid metaplasia (MMM), idiopathic myelofibrosis) (167)
– Go to question 169
Myeloproliferative neoplasm (MPN), unclassifiable (60) – Go to question 169
Chronic myelomonocytic leukemia (CMMoL) (54) – Go to question 169
Myelodysplastic / myeloproliferative neoplasm, unclassifiable (69) – Go to question 169
Transformed to AML (70) – Go to question 170
63.
Specify the date of the most recent transformation:___ ___ ___ ___ — ___ ___ — ___ ___ - Go to
question 171
64.
Date of MDS diagnosis: ___ ___ ___ ___ - ___ ___ - ___ ___ – Go to signature line
CIBMTR Form 2402 revision 21 (page 54 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Laboratory studies at last evaluation prior to the start of the preparative regimen:
65.
WBC
Known
Unknown
66.
___ ___ ___ ___ ___ ___ ● ___ x 109/L (x 103/mm3)
x 106/L
67.
Hemoglobin
Known
Unknown
68.
___ ___ ___ ___ ● ___ ___
g/L
mmol/L
g/dL
69.
Was RBC transfused ≤ 30 days before date of test?
Yes
No
70.
Platelets
Known
Unknown
71.
___ ___ ___ ___ ___ ___ ___ x 109/L (x 103/mm3)
x 106/L
72.
Were platelets transfused ≤ 7 days before date of test?
Yes
No
73.
Neutrophils
Known
Unknown
74.
75.
___ ___%
Blasts in bone marrow
Known
CIBMTR Form 2402 revision 21 (page 55 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Unknown
76.
77.
___ ___ ___ %
Were cytogenetics tested (karyotyping or FISH)?
Yes – Go to question 184
No – Go to question 211
Unknown – Go to question 211
78.
Results of tests:
Abnormalities identified – Go to question 185
No evaluable metaphases – Go to question 211
No abnormalities – Go to question 211
Specify cytogenetic abnormalities identified at last evaluation prior to the start of the preparative
regimen:
79.
Specify number of distinct cytogenetic abnormalities:
One (1)
Two (2)
Three (3)
Four or more (4 or more)
Monosomy
80.
–5
Yes
No
81. –7
Yes
No
82. –13
Yes
No
83. –20
CIBMTR Form 2402 revision 21 (page 56 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Yes
No
84. –Y
Yes
No
Trisomy
85. +8
Yes
No
86. +19
Yes
No
Translocation
87. t(1;3)
Yes
No
88. t(2;11)
Yes
No
89. t(3;3)
Yes
No
90. t(3;21)
Yes
No
91. t(6;9)
Yes
No
92. t(11;16)
CIBMTR Form 2402 revision 21 (page 57 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Yes
No
Deletion
93. del(3q) / 3q-
Yes
No
94. del(5q) / 5q-
Yes
No
95. del(7q) / 7q-
Yes
No
96. del(9q) / 9q-
Yes
No
97. del(11q) / 11q-
Yes
No
98. del(12p) / 12p-
Yes
No
99. del(13q) / 13q-
Yes
No
100. del(20q) / 20q-
Yes
No
Inversion
101. inv(3)
CIBMTR Form 2402 revision 21 (page 58 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Yes
No
Other
102. i17q
Yes
No
103. Other abnormality
Yes – Go to question 210
No – Go to question 211
104.
Specify other abnormality: ______________________________________________
Status at transplantation:
105.
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;
platelets ≥ 100 x 109/L without thrombopoietic support; 0% blasts - Go to question 215
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 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 pretreatment platelet count of < 20 x 109/L, platelet absolute increase of ≥ 20 x 109/L and ≥ 100% from pretreatment level * HI-N – neutrophil count increase of ≥ 100% from pre-treatment level and an absolute
increase of ≥ 500/mm3 - Go to question 212
No response (NR) / stable disease (SD) – does not meet the criteria for at least HI, but no evidence of
disease progression - Go to question 215
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 213
Relapse from complete remission (Rel from CR) – requires at least one of the following: * return to pretreatment 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 214
Not assessed - Go to signature line
106.
Specify the cell line examined to determine HI status:
CIBMTR Form 2402 revision 21 (page 59 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
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 215
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 – Go to question 215
HI-N – neutrophil count increase of ≥ 100% from pre-treatment level and an absolute increase of ≥
500/mm3 - Go to question 215
107.
Date of progression: ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to question 215
YYYY
108.
DD
Date of relapse: ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to question 215
YYYY
109.
MM
Date assessed:
MM
DD
___ ___ ___ ___ — ___ ___ — ___ ___- Go to signature line
YYYY
MM
DD
Other Leukemia (OL)
110.
Specify the other leukemia classification:
Chronic lymphocytic leukemia (CLL), NOS (34) - Go to question 218
Chronic lymphocytic leukemia (CLL), B-cell / small lymphocytic lymphoma (SLL) (71) - Go to question 218
Hairy cell leukemia (35) - Go to question 221
Hairy cell leukemia variant (75) - Go to question 221
Monoclonal B-cell lymphocytosis (76) – Go to signature line
Prolymphocytic leukemia (PLL), NOS (37) - Go to question 218
PLL, B-cell (73) - Go to question 218
PLL, T-cell (74) - Go to question 218
Other leukemia, NOS (30) - Go to question 220
Other leukemia (39) - Go to question 217
111. Specify other leukemia: _________________________________________ – Go to question 220
112. Was any 17p abnormality detected?
Yes – If disease classification is CLL, go to question 219. If PLL, go to question 221.
No
CIBMTR Form 2402 revision 21 (page 60 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
113. Did a histologic transformation to diffuse large B-cell lymphoma (Richter syndrome) occur at any time after
CLL diagnosis?
Yes – Go to question 226– Also complete NHL Disease Classification questions
No – Go to question 221
Status at transplantation:
114. What was the disease status? (Atypical CML)
Primary induction failure – Go to question 222
1st complete remission (no previous bone marrow or extramedullary relapse) – Go to question 222
2nd complete remission – Go to question 222
≥ 3rd complete remission – Go to question 222
1st relapse – Go to question 222
2nd relapse – Go to question 222
≥ 3rd relapse – Go to question 222
No treatment – Go to signature line
115. What was the disease status? (CLL, PLL, Hairy cell leukemia)
Complete remission (CR) – Go to question 222
Partial remission (PR) – Go to question 222
Stable disease (SD) – Go to question 222
Progressive disease (Prog) – Go to question 222
Untreated - Go to question 222
Not assessed - Go to signature line
116.
Date assessed: ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to signature line
YYYY
MM
DD
Hodgkin Lymphoma
117.
Specify Hodgkin lymphoma classification:
Nodular lymphocyte predominant Hodgkin lymphoma (155)
Lymphocyte-rich (151)
Nodular sclerosis (152)
Mixed cellularity (153)
Lymphocyte depleted (154)
CIBMTR Form 2402 revision 21 (page 61 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Hodgkin lymphoma, NOS (150)
Status at transplantation:
118.
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
CR1 - 1st complete remission: no bone marrow or extramedullary relapse prior to transplant
CR2 - 2nd complete remission
CR3+ - 3rd or subsequent complete remission
REL1 unt - 1st relapse – untreated; includes either bone marrow or extramedullary relapse
REL1 res - 1st relapse – resistant: stable or progressive disease with treatment
REL1 sen - 1st relapse – sensitive: partial remission (if complete remission was achieved, classify as CR2)
REL1 unk - 1st relapse – sensitivity unknown
REL2 unt - 2nd relapse – untreated: includes either bone marrow or extramedullary relapse
REL2 res - 2nd relapse – resistant: stable or progressive disease with treatment
REL2 sen - 2nd relapse – sensitive: partial remission (if complete remission achieved, classify as CR3+)
REL2 unk - 2nd relapse – sensitivity unknown
REL3+ unt - 3rd or subsequent relapse – untreated; includes either bone marrow or extramedullary relapse
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 - 3rd relapse or greater – sensitivity unknown
119.
Date assessed: ___ ___ ___ ___ - ___ ___ - ___ ___ - Go to signature line
YYYY
MM
DD
Non-Hodgkin Lymphoma
120.
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)
CIBMTR Form 2402 revision 21 (page 62 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
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 227
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 227
121. Specify other lymphoma: _________________________________________________________
122.
Is the non-Hodgkin lymphoma histology reported at diagnosis a transformation from CLL?
CIBMTR Form 2402 revision 21 (page 63 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Yes – Go to question 230- Also complete CLL Disease Classification questions
No - Go to question 229
123. Is the non-Hodgkin lymphoma histology reported a transformation from, or was it diagnosed at the same
time as another lymphoma (not CLL)?
Yes
No
Status at transplantation:
124.
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
CR1 - 1st complete remission: no bone marrow or extramedullary relapse prior to transplant
CR2 - 2nd complete remission
CR3+ - 3rd or subsequent complete remission
REL1 unt - 1st relapse – untreated; includes either bone marrow or extramedullary relapse
REL1 res - 1st relapse – resistant: stable or progressive disease with treatment
REL1 sen - 1st relapse – sensitive: partial remission (if complete remission was achieved, classify as CR2)
REL1 unk - 1st relapse – sensitivity unknown
REL2 unt - 2nd relapse – untreated: includes either bone marrow or extramedullary relapse
REL2 res - 2nd relapse – resistant: stable or progressive disease with treatment
REL2 sen - 2nd relapse – sensitive: partial remission (if complete remission achieved, classify as CR3+)
REL2 unk - 2nd relapse – sensitivity unknown
REL3+ unt - 3rd or subsequent relapse – untreated; includes either bone marrow or extramedullary relapse
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 - 3rd relapse or greater – sensitivity unknown
125.
Date assessed: ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to signature line
YYYY
MM
CIBMTR Form 2402 revision 21 (page 64 of 77) Draft 37/236/20176
DD
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Multiple Myeloma / Plasma Cell Disorder (PCD)
126.
Specify the multiple myeloma/plasma cell disorder (PCD) classification:
Multiple myeloma-lgG (181) - Go to questions 234
Multiple myeloma-lgA (182) - Go to questions 234
Multiple myeloma-lgD (183) - Go to questions 234
Multiple myeloma-lgE (184) - Go to questions 234
Multiple myeloma-lgM (not Waldenstrom macroglobulinemia) (185) - Go to questions 234
Multiple myeloma-light chain only (186) - Go to questions 234
Multiple myeloma-non-secretory (187) - Go to questions 235
Plasma cell leukemia (172) - Go to question 240
Solitary plasmacytoma (no evidence of myeloma) (175) - Go to question 240
Amyloidosis (174) - Go to question 240
Osteosclerotic myeloma / POEMS syndrome (176) - Go to questions 240
Light chain deposition disease (177) - Go to questions 240
Other plasma cell disorder (179) - Go to question 233
127. Specify other plasma cell disorder: _________________________________ - Go to question 240
128.
Light chain
kappa
lambda
129. 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 236
Stage II (Fitting neither Stage I or Stage III) – Go to questions 236
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 236
Unknown – Go to questions 237
130. 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.:
CIBMTR Form 2402 revision 21 (page 65 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
131.
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Serum β2-microglobulin: ___ ___ ___ ● ___ ___ ___
μg/dL
mg/L
nmol/L
132.
Serum albumin: ___ ___ ● ___
g/dL
g/L
133. Stage
1 (β2-mic < 3.5, S. albumin ≥ 3.5)
2 (β2-mic 3.5–< 5.5, S. albumin —)
3 (β2-mic ≥ 5.5; S. albumin —)
134.
Were cytogenetics tested (karyotyping or FISH)?
Yes – Go to questions 241
No – Go to question 262
Unknown – Go to question 262
135. Results of tests:
Abnormalities identified – Go to question 242
No evaluable metaphases – Go to question 262
No abnormalities – Go to question 262
Specify cytogenetic abnormalities identified at any time prior to the start of the preparative
regimen:
Trisomy
136. +3
Yes
No
137. +5
Yes
No
138. +7
Yes
No
139. +9
CIBMTR Form 2402 revision 21 (page 66 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
Yes
No
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
140. +11
Yes
No
141. +15
Yes
No
142. +19
Yes
No
Translocation
143. t(4;14)
Yes
No
144.
t(6;14)
Yes
No
145. t(11;14)
Yes
No
146. t(14;16)
Yes
No
147. t(14;20)
Yes
No
Deletion
148. del (13)/13qCIBMTR Form 2402 revision 21 (page 67 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
Yes
No
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
149. del (17)/17p
Yes
No
Other
150. Hyperdiploid (>50)
Yes
No
151. Hypodiploid (<46)
Yes
No
152. Any abnormality at 1q
Yes
No
153. Any abnormality at 1p
Yes
No
154. Other abnormality
Yes
No
155. Specify other abnormality:______________________________________________
Status at transplantation:
156.
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 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. - Go to question 263
CIBMTR Form 2402 revision 21 (page 68 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
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. - Go to question 263
Near complete remission (nCR) — serum and 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. - Go to question 263
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. - Go to question 263
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. - Go to
question 263
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. - Go to question 263
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 Mcomponent and/or (absolute increase ≥ 200 mg/24 hours) for recipients without measurable serum and urine Mprotein 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 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 - Go to question 263
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. – Go to question 263
Unknown – Go to signature line
Not applicable (Amyloidosis with no evidence of myeloma) – Go to signature line
157.
Date assessed: ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to signature line
CIBMTR Form 2402 revision 21 (page 69 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
YYYY
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
MM
DD
Solid Tumors
158.
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)
Hepatobiliary (207)
CIBMTR Form 2402 revision 21 (page 70 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
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 (270) – Go to question 265
Solid tumor, not otherwise specified (200)
159.
Specify other solid tumor: ___________________________________
- Go to signature line
Severe Aplastic Anemia
160.
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) – Go to question 267
161.
Specify other acquired cytopenic syndrome: _______________________________
- Go to signature line
Inherited Abnormalities of Erythrocyte Differentiation or Function
162.
Specify the inherited abnormalities of erythrocyte differentiation or function classification:
CIBMTR Form 2402 revision 21 (page 71 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Paroxysmal nocturnal hemoglobinuria (PNH) (56)
Shwachman-Diamond (305)
Diamond-Blackfan anemia (pure red cell aplasia) (312)
Other constitutional anemia (319) – Go to question 269
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) – Go to question 270
163.
Specify other constitutional anemia: ____________________________________
164.
Specify other hemoglobinopathy:__________________________________
- Go to signature line
Disorders of the Immune System
165.
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) – Go to question 272
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 adhesion deficiencies (459)
Kostmann agranulocytosis (congenital neutropenia) (460)
Neutrophil actin deficiency (461)
CIBMTR Form 2402 revision 21 (page 72 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Cartilage-hair hypoplasia (462)
CD40 ligand deficiency (464)
Other immunodeficiencies (479) – Go to question 273
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)
166.
Specify other SCID: ____________________________
167.
Specify other immunodeficiency: ____________________________
- Go to signature line
Inherited Abnormalities of Platelets
168.
Specify inherited abnormalities of platelets classification:
Congenital amegakaryocytosis / congenital thrombocytopenia (501)
Glanzmann thrombasthenia (502)
Other inherited platelet abnormality (509) – Go to question 275
169.
Specify other inherited platelet abnormality: ___________________________________
- Go to signature line
Inherited Disorders of Metabolism
170.
Specify inherited disorders of metabolism classification:
Osteopetrosis (malignant infantile osteopetrosis) (521)
Leukodystrophies
Metachromatic leukodystrophy (MLD) (542)
Adrenoleukodystrophy (ALD) (543)
CIBMTR Form 2402 revision 21 (page 73 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
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)
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) – Go to question 277
Inherited metabolic disorder, not otherwise specified (520)
171.
Specify other inherited metabolic disorder: ___________________________________
- Go to signature line
Histiocytic disorders
172.
Specify histiocytic disorder classification:
CIBMTR Form 2402 revision 21 (page 74 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Hemophagocytic lymphohistiocytosis (HLH) (571)
Langerhans cell histiocytosis (histiocytosis-X) (572)
Hemophagocytosis (reactive or viral associated) (573)
Malignant histiocytosis (574)
Other histiocytic disorder (579) – Go to question 279
Histiocytic disorder, not otherwise specified (570)
173.
Specify other histiocytic disorder: ________________________________________
- Go to signature line
Autoimmune Diseases
174.
Specify autoimmune disease classification:
Arthritis
Rheumatoid arthritis (603)
Psoriatic arthritis / psoriasis (604)
Juvenile idiopathic arthritis (JIA): systemic (Stills disease) (640)
Juvenile idiopathic arthritis (JIA): oligoarticular (641)
Juvenile idiopathic arthritis (JIA): polyarticular (642)
Juvenile idiopathic arthritis (JIA): other (643) Go to question 282
Other arthritis (633) – Go to question 281
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) – Go to question 283
Vasculitis
Wegener granulomatosis (610)
Classical polyarteritis nodosa (631)
Microscopic polyarteritis nodosa (632)
CIBMTR Form 2402 revision 21 (page 75 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Churg-Strauss (635)
Giant cell arteritis (636)
Takayasu (637)
Behcet syndrome (638)
Overlap necrotizing arteritis (639)
Other vasculitis (611) – Go to question 284
Other neurological autoimmune diseases
Myasthenia gravis (601)
Other autoimmune neurological disorder (644) – Go to question 285
Hematological autoimmune diseases
Idiopathic thrombocytopenic purpura (ITP) (645)
Hemolytic anemia (646)
Evan syndrome (647)
Other autoimmune cytopenia (648) – Go to question 286
Bowel diseases
Crohn’s disease (649)
Ulcerative colitis (650)
Other autoimmune bowel disorder (651) – Go to question 287
175.
Specify other arthritis:_________________________________
176.
Specify other juvenile idiopathic arthritis (JIA):_________________________________
177.
Specify other connective tissue disease:_________________________________
178.
Specify other vasculitis:_________________________________
179.
Specify other autoimmune neurological disorder:_________________________________
180.
Specify other autoimmune cytopenia:_________________________________
181.
Specify other autoimmune bowel disorder:_________________________________
- Go to signature line
Other Disease
CIBMTR Form 2402 revision 21 (page 76 of 77) Draft 37/236/20176
CIBMTR Center Number: ___ ___ ___ ___ ___
182.
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Specify other disease: _________________________________________
First Name: ____________________________________________________________________________
Last Name: ________________________________________________________________________________
E-mail address: ____________________________________________________________________________
Date: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY
MM
DD
CIBMTR Form 2402 revision 21 (page 77 of 77) Draft 37/236/20176
| File Type | application/pdf |
| File Title | Microsoft Word - Draft Pre-TED 2402 - Disease Classification r2.docx |
| Author | doleysh |
| File Modified | 2017-04-18 |
| File Created | 2017-04-18 |