F2402 R2 (current)

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: __ __ __ __ / __ __ / __ __

YYYY
MM
DD

CIBMTR Form 2402 revision 2 (page 1 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Primary Disease for HCT / Cellular Therapy
1. Date of diagnosis of primary disease for HCT / cellular therapy: __ __ __ __ / __ __ / __ __

YYYY
MM
DD

2. What was the primary disease for which the HCT / cellular therapy was performed?

☐ Acute myelogenous leukemia (AML or ANLL) (10) - Go to question 3
☐ Acute lymphoblastic leukemia (ALL) (20) - Go to question 88
☐ Acute leukemia of ambiguous lineage and other myeloid neoplasms (80) - Go to question 150
☐ Chronic myelogenous leukemia (CML) (40) - Go to question 154
☐ Myelodysplastic (MDS) / myeloproliferative (MPN) diseases (50) (Please classify all pre-leukemias) (If recipient has transformed to AML,

indicate AML as the primary disease) - Go to question 165

- Go to question 309

☐ Other leukemia (30) (includes CLL) - Go to question 261
☐ Hodgkin lymphoma (150) - Go to question 266
☐ Non-Hodgkin lymphoma (100) - Go to question 269
☐ Multiple myeloma / plasma cell disorder (PCD) (170) - Go to question 275
☐ Solid tumors (200) - Go to question 307
☐ Severe aplastic anemia (300) (If the recipient developed MDS or AML, indicate MDS or AML as the primary disease)
☐ Inherited abnormalities of erythrocyte differentiation or function (310) - Go to question 311
☐ Disorders of the immune system (400) - Go to question 314
☐ Inherited abnormalities of platelets (500) - Go to question 317
☐ Inherited disorders of metabolism (520) - Go to question 319
☐ Histiocytic disorders (570) - Go to question 321
☐ Autoimmune diseases (600) - Go to question 323
☐ Other disease (900) - Go to question 331

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)
☐ 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)

CIBMTR Form 2402 revision 2 (page 2 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

AML, not otherwise specified

4.

Did AML transform from MDS or MPN?

5.

Is the disease (AML) therapy related?

6.

Did the recipient have a predisposing condition?

☐ AML, not otherwise specified (280)
☐ AML, minimally differentiated (286)
☐ 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)

☐ Yes
☐ No
☐ Unknown

7.

☐ Yes – Also complete MDS Disease Classification questions ☐ No
☐ Yes ☐ No ☐ Unknown

Specify condition:

☐ Bloom syndrome
☐ Down syndrome

☐ Fanconi anemia – Also complete CIBMTR Form 2029

☐ Dyskeratosis congenita

☐ Other condition

8.

Specify other condition:_________________________

Labs at diagnosis
9.

Were cytogenetics tested (karyotyping or FISH)? (at diagnosis)

☐ Yes
☐ No
☐ Unknown

10. Were cytogenetics tested via FISH?

☐ Yes
☐ No

11.

Results of tests:

☐ Abnormalities identified
☐ No abnormalities
Specify cytogenetic abnormalities identified at diagnosis:
12.

Specify number of distinct cytogenetic abnormalities:

13.

Specify abnormalities (check all that apply)

☐ One (1)
☐ Two (2)
☐ Three (3)
☐ Four or more (4 or more)
☐ -5
☐ -7

CIBMTR Form 2402 revision 2 (page 3 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

☐ -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
☐ 12p any abnormality
☐ Other abnormality

14. Specify other
abnormality:

CIBMTR Form 2402 revision 2 (page 4 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

______________

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

15. Were cytogenetics tested via karyotyping?

☐ Yes
☐ No

16.

Results of tests:

☐ Abnormalities identified
☐ No evaluable metaphases
☐ No abnormalities
Specify cytogenetic abnormalities identified at diagnosis:
17.

Specify number of distinct cytogenetic abnormalities:

18.

Specify abnormalities: (check all that apply)

☐ One (1)
☐ Two (2)
☐ Three (3)
☐ Four or more (4 or more)
☐ -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–

CIBMTR Form 2402 revision 2 (page 5 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

☐ inv(3)
☐ inv(16)
☐ (11q23) any abnormality
☐ 12p any abnormality
☐ Other abnormality

19. Specify other
abnormality:

20. Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)

______________

☐ Yes

☐ No

21. Were tests for molecular markers performed (e.g. PCR, NGS)? (at diagnosis)

☐ Yes
☐ No
☐ Unknown

Specify molecular markers identified at diagnosis:
22. CEBPA

☐ Positive
☐ Negative
☐ Not done

23.

Specify CEBPA mutation

☐ Biallelic (homozygous)
☐ Monoallelic (heterozygous)
☐ Unknown
☐ Positive

24. FLT3 – D835 point mutation

☐ Negative

☐ Not done

25. FLT3 – ITD mutation

☐ Positive
☐ Negative
☐ Not done

28. IDH1
29. IDH2
30. KIT
31. NPM1

26.

FLT3 – ITD allelic ratio

☐ Known
☐ Unknown

27.

☐ Positive
☐ Positive
☐ Positive
☐ Positive

32. Other molecular marker

Specify FLT3 - ITD allelic ratio:
___ ● ___

☐ Negative
☐ Negative
☐ Negative
☐ Negative

☐ Not done
☐ Not done
☐ Not done
☐ Not done

☐ Positive
33. Specify other molecular marker:________________________
☐ Negative
☐ Not done

Copy and complete questions 32-33 for multiple molecular markers.

CIBMTR Form 2402 revision 2 (page 6 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Labs between diagnosis and last evaluation:
34. Were cytogenetics tested (karyotyping or FISH)? (between diagnosis and last evaluation)

☐ Yes
☐ No
☐ Unknown

35. Were cytogenetics tested via FISH?

☐ Yes
☐ No

36.

Results of tests:

☐ Abnormalities identified
☐ No abnormalities
Specify cytogenetic abnormalities identified between diagnosis
and last evaluation:
37.

Specify number of distinct cytogenetic abnormalities:

38.

Specify abnormalities (check all that apply)

☐ One (1)
☐ Two (2)
☐ Three (3)
☐ Four or more (4 or more)
☐ -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–

CIBMTR Form 2402 revision 2 (page 7 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

☐ del(20q) / 20q–
☐ del(21q) / 21q–
☐ inv(3)
☐ inv(16)
☐ (11q23) any abnormality
☐ 12p any abnormality
☐ Other abnormality

39. Specify other
abnormality:

______________

40. Were cytogenetics tested via karyotyping?

☐ Yes
☐ No

41.

Results of tests:

☐ Abnormalities identified
☐ No evaluable metaphases
☐ No abnormalities

Specify cytogenetic abnormalities identified between diagnosis
and last evaluation:
42.

Specify number of distinct cytogenetic abnormalities:

43.

Specify abnormalities (check all that apply)

☐ One (1)
☐ Two (2)
☐ Three (3)
☐ Four or more (4 or more)
☐ -5
☐ -7
☐ -17
☐ -18
☐ -X
☐ -Y
☐ +4
☐ +8
☐ +11
☐ +13
☐ +14
☐ +21
☐ +22
☐ t(3;3)
☐ t(6;9)

CIBMTR Form 2402 revision 2 (page 8 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

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

44. Specify other
abnormality:

45. Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)

______________

☐ Yes

☐ No

46. Were tests for molecular markers performed (e.g. PCR, NGS)? (between diagnosis and last evaluation)

☐ Yes
☐ No
☐ Unknown

Specify molecular markers identified between diagnosis and last evaluation:
47. CEBPA

☐ Positive
☐ Negative
☐ Not done

48.

Specify CEBPA mutation

☐ Biallelic (homozygous)
☐ Monoallelic (heterozygous)
☐ Unknown
☐ Positive

49. FLT3 – D835 point mutation

☐ Negative

☐ Not done

50. FLT3 – ITD mutation

☐ Positive
☐ Negative
☐ Not done

53. IDH1
54. IDH2
CIBMTR Form 2402 revision 2 (page 9 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

51.

FLT3 – ITD allelic ratio

☐ Known
☐ Unknown

52.

Specify FLT3 - ITD allelic ratio:
___ ● ___

☐ Positive
☐ Positive

☐ Negative
☐ Negative

☐ Not done
☐ Not done

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

☐ Positive
☐ Positive

55. KIT
56. NPM1

☐ Negative
☐ Negative

☐ Not done
☐ Not done

57. Other molecular marker

☐ Positive
58. Specify other molecular marker:________________________
☐ Negative
☐ Not done

Copy and complete questions 57-58 to report multiple other molecular markers.
Labs at last evaluation:
59. Were cytogenetics tested (karyotyping or FISH)? (at last evaluation)

☐ Yes
☐ No
☐ Unknown

60. Were cytogenetics tested via FISH?

☐ Yes
☐ No

61.

Results of tests:

☐ Abnormalities identified
☐ No abnormalities
Specify cytogenetic abnormalities identified at last evaluation:
62.

Specify number of distinct cytogenetic abnormalities:

63.

Specify abnormalities (check all that apply)

☐ One (1)
☐ Two (2)
☐ Three (3)
☐ Four or more (4 or more)
☐ -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)

CIBMTR Form 2402 revision 2 (page 10 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

☐ 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

64. Specify other
abnormality:

______________

65. Were cytogenetics tested via karyotyping?

☐ Yes
☐ No

66.

Results of tests:

☐ Abnormalities identified
☐ No evaluable metaphases
☐ No abnormalities

Specify cytogenetic abnormalities identified at last evaluation:
67.

Specify number of distinct cytogenetic abnormalities:

68.

Specify abnormalities (check all that apply)

☐ One (1)
☐ Two (2)
☐ Three (3)
☐ Four or more (4 or more)
☐ -5
☐ -7
☐ -17
☐ -18
☐ -X
☐ -Y
☐ +4

CIBMTR Form 2402 revision 2 (page 11 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

☐ +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
☐ 12p any abnormality
☐ Other abnormality

69. Specify other
abnormality:

70. Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)

CIBMTR Form 2402 revision 2 (page 12 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

______________

☐ Yes

☐ No

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

71. Were tests for molecular markers performed (e.g. PCR, NGS)? (at last evaluation)

☐ Yes
☐ No
☐ Unknown

Specify molecular markers identified at last evaluation:
72. CEBPA

☐ Positive
☐ Negative
☐ Not done

73.

Specify CEBPA mutation

☐ Biallelic (homozygous)
☐ Monoallelic (heterozygous)
☐ Unknown
☐ Positive

74. FLT3 – D835 point mutation

☐ Negative

☐ Not done

75. FLT3 – ITD mutation

☐ Positive
☐ Negative
☐ Not done

76.

FLT3 – ITD allelic ratio

☐ Known
☐ Unknown

77.

Specify FLT3 - ITD allelic ratio:
___ ● ___

☐ Positive
☐ Positive
☐ Positive
☐ Positive

78. IDH1
79. IDH2
80. KIT
81. NPM1

☐ Negative
☐ Negative
☐ Negative
☐ Negative

☐ Not done
☐ Not done
☐ Not done
☐ Not done

82. Other molecular marker

☐ Positive
83. Specify other molecular marker:________________________
☐ Negative
☐ Not done

Copy and complete questions 82-83 to report multiple other molecular markers.
CNS Leukemia
84. Did the recipient have central nervous system leukemia at any time prior to the start of the preparative regimen / infusion?

☐ Yes

☐ No

☐ Unknown

Status at transplantation:
85. What was the disease status (based on hematological test

results)?

☐ Primary induction failure - Go to question 89
☐ 1st complete remission (no previous bone marrow or

extramedullary relapse) (include CRi) - Go to question 86

☐ 2nd complete remission - Go to question 86
☐ ≥ 3rd complete remission - Go to question 86

☐ 1st relapse - Go to question 88
☐ 2nd relapse - Go to question 88

☐ ≥ 3rd relapse - Go to question 88

☐ No treatment - Go to question 89

86.

☐ 1 ☐ 2 ☐ ≥ 3

87. Was the recipient in remission by flow cytometry?

☐ Yes

☐ No ☐ Unknown

☐ Not applicable

88. Date of most recent relapse:__ __ __ __ / __ __ / __ __

YYYY
MM
DD

89. Date assessed: __ __ __ __ / __ __ / __ __ - Go to signature line

YYYY
MM
DD

CIBMTR Form 2402 revision 2 (page 13 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

How many cycles of induction therapy were required to achieve
1st complete remission? (includes CRi)

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Acute Lymphoblastic Leukemia (ALL)
90. 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)
91. Did the recipient have a predisposing condition?

☐ Yes
☐ No
☐ Unknown

92. Specify condition:

☐ Aplastic anemia – Also complete CIBMTR Form 2028 — APL
☐ Bloom syndrome
☐ Down syndrome
☐ Fanconi anemia – Also complete CIBMTR Form 2029 — FAN
☐ Other condition
93.

Specify other condition:________________________________

94. Were tyrosine kinase inhibitors given for therapy at any time prior to start of the preparative regimen / infusion? (e.g. imatinib mesylate,

dasatinib, etc.)

☐ Yes

☐ No

Laboratory studies at diagnosis:
95. Were cytogenetics tested (karyotyping or FISH)? (at diagnosis)

☐ Yes
☐ No
☐ Unknown

96. Were cytogenetics tested via FISH? (at diagnosis)

☐ Yes
☐ No

97. Results of tests: (at diagnosis)

☐ Abnormalities identified
☐ No abnormalities

Specify cytogenetic abnormalities identified:
98.

Specify number of distinct cytogenetic abnormalities:

☐ One (1)
☐ Two (2)
☐ Three (3)
☐ Four or more (4 or more)
CIBMTR Form 2402 revision 2 (page 14 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

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)
☐ iAMP21
☐ Other abnormality

100. Specify other
abnormality:

______________

101. Were cytogenetics tested via karyotyping? (at diagnosis)

☐ Yes
☐ No

102. Results of tests: (at diagnosis)

☐ Abnormalities identified
☐ No evaluable metaphases
☐ No abnormalities

Specify cytogenetic abnormalities identified:
103. Specify number of distinct cytogenetic abnormalities:

☐ One (1)
☐ Two (2)
☐ Three (3)
☐ Four or more (4 or more)
CIBMTR Form 2402 revision 2 (page 15 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

104. 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)
☐ iAMP21
☐ Other abnormality

105. Specify other
abnormality:

______________

106. Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)

☐ Yes

☐ No

107. Were tests for molecular markers performed (e.g. PCR, NGS)? (at diagnosis)

☐ Yes

☐ No
☐ Unknown

Specify molecular markers identified at diagnosis:
108. BCR / ABL
109. TEL-AML / AML1

☐ Positive
☐ Positive

110. Other molecular marker

☐ Negative
☐ Negative

☐ Not done
☐ Not done

☐ Positive
111. Specify other molecular marker:_________________________
☐ Negative
☐ Not done

Copy and complete questions 110-111 for additional molecular markers
CIBMTR Form 2402 revision 2 (page 16 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Laboratory studies between diagnosis and last evaluation:
112. Were cytogenetics tested (karyotyping or FISH)? (between diagnosis and last evaluation)

☐ Yes
☐ No
☐ Unknown

113. Were cytogenetics tested via FISH? (between diagnosis and the last evaluation)

☐ Yes
☐ No

114. Results of tests: (between diagnosis and the last evaluation)

☐ Abnormalities identified
☐ No abnormalities

Specify cytogenetic abnormalities identified:
115. Specify number of distinct cytogenetic abnormalities:

☐ One (1)
☐ Two (2)
☐ Three (3)
☐ Four or more (4 or more)

116. 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)
☐ iAMP21
☐ Other abnormality

117. Specify other
abnormality:

CIBMTR Form 2402 revision 2 (page 17 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

______________

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

118. Were cytogenetics tested via karyotyping? (between diagnosis and the last evaluation)

☐ Yes
☐ No

119. Results of tests: (between diagnosis and the last evaluation)

☐ Abnormalities identified
☐ No evaluable metaphases

☐ No abnormalities

Specify cytogenetic abnormalities identified:
120. Specify number of distinct cytogenetic abnormalities:

☐ One (1)
☐ Two (2)
☐ Three (3)
☐ Four or more (4 or more)

121. 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)
☐ iAMP21
☐ Other abnormality

122. Specify other
abnormality:

______________

123. Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)

☐ Yes

CIBMTR Form 2402 revision 2 (page 18 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

☐ No

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

124. Were tests for molecular markers performed (e.g. PCR, NGS)? (between diagnosis and last evaluation)

☐ Yes
☐ No
☐ Unknown

Specify molecular markers identified between diagnosis and last evaluation:

☐ Positive
☐ Positive

125. BCR / ABL
126. TEL-AML / AML1

☐ Negative
☐ Negative

☐ Not done
☐ Not done

127. Other molecular marker

☐ Positive
128. Specify other molecular marker:_________________________
☐ Negative
☐ Not done

Copy and complete questions 127-128 for additional molecular markers
Laboratory studies at last evaluation:
129. Were cytogenetics tested (karyotyping or FISH)? (at last evaluation)

☐ Yes
☐ No
☐ Unknown

130. Were cytogenetics tested via FISH?

☐ Yes
☐ No

131. Results of tests:

☐ Abnormalities identified
☐ No abnormalities
Specify cytogenetic abnormalities identified at last evaluation:
132. Specify number of distinct cytogenetic abnormalities:

☐ One (1)
☐ Two (2)
☐ Three (3)
☐ Four or more (4 or more)

133. 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–

CIBMTR Form 2402 revision 2 (page 19 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

☐ del(12p) / 12p–
☐ add(14q)
☐ (11q23) any abnormality
☐ 9p any abnormality
☐ 12p any abnormality
☐ Hyperdiploid (> 50)
☐ Hypodiploid (< 45)
☐ iAMP21
☐ Other abnormality

134. Specify other
abnormality:

______________

135. Were cytogenetics tested via karyotyping? (at last evaluation)

☐ Yes
☐ No

136. Results of tests:

☐ Abnormalities identified
☐ No evaluable metaphases

☐ No abnormalities

Specify cytogenetic abnormalities identified at last evaluation:
137. Specify number of distinct cytogenetic abnormalities:

☐ One (1)
☐ Two (2)
☐ Three (3)
☐ Four or more (4 or more)

138. 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)

CIBMTR Form 2402 revision 2 (page 20 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

☐ del(6q) / 6q–
☐ del(9p) / 9p–
☐ del(12p) / 12p–
☐ add(14q)
☐ (11q23) any abnormality
☐ 9p any abnormality
☐ 12p any abnormality
☐ Hyperdiploid (> 50)
☐ Hypodiploid (< 45)
☐ iAMP21
☐ Other abnormality

139. Specify other
abnormality:

______________

140. Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)

☐ Yes

☐ No

141. Were tests for molecular markers performed (e.g. PCR, NGS)? (at last evaluation)

☐ Yes
☐ No
☐ Unknown

Specify molecular markers identified at last evaluation:

☐ Positive
☐ Positive

142. BCR / ABL
143. TEL-AML / AML1

☐ Negative
☐ Negative

☐ Not done
☐ Not done

144. Other molecular marker

☐ Positive
145. Specify other molecular marker:_________________________
☐ Negative
☐ Not done

Copy and complete questions 144-145 for additional molecular markers
CNS Leukemia
146. Did the recipient have central nervous system leukemia at any time prior to the start of the preparative regimen / infusion?

☐ Yes

☐ No

☐ Unknown

Status at transplantation:
147. What was the disease status (based on hematological test results)?

☐ Primary induction failure - Go to question 151
☐ 1st complete remission (no previous marrow or

extramedullary relapse) (include CRi) - Go to question 148

☐ 2nd complete remission - Go to question 148

☐ ≥ 3rd complete remission - Go to question 148

☐ 1st relapse - Go to question 150
☐ 2nd relapse - Go to question 150

☐ ≥ 3rd relapse - Go to question 150

☐ No treatment - Go to question 151

148. How many cycles of induction therapy were required to achieve

1st complete remission (includes CRi)?

☐ 1 ☐ 2 ☐ ≥ 3

149. Was the recipient in remission by flow cytometry?

☐ Yes

☐ No ☐ Unknown ☐ Not applicable

150. Date of most recent relapse:__ __ __ __ / __ __ / __ __

YYYY
MM
DD

151. Date assessed: __ __ __ __ / __ __ / __ __ - Go to signature line

YYYY
MM
DD
CIBMTR Form 2402 revision 2 (page 21 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Acute Leukemias of Ambiguous Lineage and Other Myeloid Neoplasms
152. Specify acute leukemias of ambiguous lineage and other myeloid neoplasm classification:

☐ Blastic plasmacytoid dendritic cell neoplasm (296)
☐ Acute undifferentiated leukemia (31)
☐ Mixed phenotype acute leukemia (MPAL) with t(9;22)(q34.1;q11.2); BCR-ABL1 (84)
☐ Mixed phenotype acute leukemia with t(v; 11q23.3); KMT2A rearranged (85)
☐ Mixed phenotype acute leukemia, B/myeloid, NOS (86)
☐ Mixed phenotype acute leukemia, T/myeloid, NOS (87)
☐ Other acute leukemia of ambiguous lineage or myeloid neoplasm (88)

153. Specify other acute leukemia of ambiguous lineage or myeloid neoplasm:

_____________________________________________________________________

Status at transplantation:
154. What was the disease status (based on hematological test results)?

☐ Primary induction failure
☐ 1st complete remission (no previous bone marrow or extramedullary relapse)

☐ 2nd complete remission

☐ ≥ 3rd complete remission

☐ 1st relapse
☐ 2nd relapse

☐ ≥ 3rd relapse

☐ No treatment

155. Date assessed: __ __ __ __ / __ __ / __ __ - Go to signature line
YYYY
MM
DD

CIBMTR Form 2402 revision 2 (page 22 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Chronic Myelogenous Leukemia (CML)
156. Was therapy given prior to this HCT?

☐ Yes
☐ No

157. Combination chemotherapy
158. Hydroxyurea (Droxia, Hydrea)
159. Tyrosine kinase inhibitor (e.g.imatinib mesylate, dasatinib, nilotinib)
160.
Interferon-α (Intron, Roferon) (includes PEG)

161. Other therapy

☐ Yes
☐ Yes
☐ Yes
☐ Yes

☐ No
☐ No
☐ No
☐ No

☐ Yes
162. Specify other therapy:_________________________________________________
☐ No

163. What was the disease status?

☐ Complete hematologic response (CHR)
☐ Chronic phase

164. Specify level of response

☐ Accelerated phase
☐ Blast phase

165. Number

166. Date assessed: __ __ __ __ / __ __ / __ __ - Go to signature line

YYYY
MM
DD

CIBMTR Form 2402 revision 2 (page 23 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

☐ 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)
☐ 1st ☐ 2nd

☐ 3rd or higher

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Myelodysplastic (MDS) / Myeloproliferative (MPN) Diseases
167. 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 anemia with excess blasts-2 (RAEB-2) (62)
☐ Refractory cytopenia with multilineage dysplasia (RCMD) (64)
☐ Childhood myelodysplastic syndrome (Refractory cytopenia of childhood (RCC)) (68)
☐ Myelodysplastic syndrome with isolated del(5q) (5q– syndrome) (66)
☐ Myelodysplastic syndrome (MDS), unclassifiable (50)
☐ Chronic neutrophilic leukemia (165)
☐ Chronic eosinophilic leukemia, NOS (166)
☐ Essential thrombocythemia (includes primary thrombocytosis, idiopathic thrombocytosis, hemorrhagic thrombocythemia) (58)
☐ 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 Ph 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)
1

☐ Yes

168. Was the disease (MDS / MPN) therapy related?

☐ No

☐ Unknown

169. Did the recipient have a predisposing condition?

☐ Yes
☐ No

☐ Unknown

170. Specify condition

☐ Aplastic anemia
☐ Bloom syndrome
☐ Down syndrome
☐ Fanconi anemia
☐ Other condition

171. Specify other condition::________________________________

Laboratory Studies at Diagnosis of MDS:
172. WBC

☐ Known
☐ Unknown

173. ___ ___ ___ ___ ___ ___ ● ___ ☐ x 109/L (x 103/mm3)

☐ x 10 /L
6

174. Hemoglobin

☐ Known
☐ Unknown

175. ___ ___ ___ ___ ● ___ ___

☐ g/dL

☐ g/L

176. Was RBC transfused ≤ 30 days before date of test?

CIBMTR Form 2402 revision 2 (page 24 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

☐ mmol/L
☐ Yes

☐ No

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

177. Platelets

☐ Known
☐ Unknown

178. ___ ___ ___ ___ ___ ___ ___ ☐ x 109/L (x 103/mm3)

☐ x 10 /L
6

179. Were platelets transfused ≤ 7 days before date of test?

☐ Yes

☐ No

180. Neutrophils

☐ Known
☐ Unknown

181. ___ ___%

182. Blasts in bone marrow

☐ Known
☐ Unknown

183. ___ ___ ___ %

184. Were cytogenetics tested (karyotyping or FISH)?

☐ Yes
☐ No
☐ Unknown

185. Results of tests:

☐ Abnormalities identified
☐ No evaluable metaphases

☐ No abnormalities

Specify abnormalities identified at diagnosis:
186. Specify number of distinct cytogenetic abnormalities:

☐ One (1)
☐ Two (2)
☐ Three (3)

☐ Four or more (4 or more)

Monosomy
187. –5
188. –7
189. –13
190. –20
191. –Y
Trisomy
192. +8
193. +19
Translocation
194. t(1;3)
195. t(2;11)
196. t(3;3)
197. t(3;21)
198. t(6;9)
199. t(11;16)
Deletion
200. del(3q) / 3q-
201. del(5q) / 5q-

CIBMTR Form 2402 revision 2 (page 25 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes

☐ No
☐ No
☐ No
☐ No
☐ No

☐ Yes
☐ Yes

☐ No
☐ No

☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes

☐ No
☐ No
☐ No
☐ No
☐ No
☐ No

☐ Yes
☐ Yes

☐ No
☐ No

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes

☐ No
☐ No
☐ No
☐ No
☐ No
☐ No

☐ Yes

☐ No

209. i17q

☐ Yes

☐ No

210. Other abnormality

202. del(7q) / 7q-
203. del(9q) / 9q-
204. del(11q) / 11q-
205. del(12p) / 12p-
206. del(13q) / 13q-
207. del(20q) / 20q-
Inversion
208. inv(3)
Other

☐ Yes
211. Specify other abnormality:____________________________
☐ No

212. Did the recipient progress or transform to a different MDS / MPN subtype between diagnosis and the start of the preparative regimen?

☐ Yes
☐ No

213. Specify the MDS / MPN subtype after transformation:

☐ Refractory cytopenia with unilineage dysplasia (RCUD) (includes refractory anemia (RA)) (51)

- Go to question 214

☐ Refractory anemia with ringed sideroblasts (RARS) (55) - Go to question 214
☐ Refractory anemia with excess blasts-1 (RAEB-1) (61) - Go to question 214
☐ Refractory anemia with excess blasts-2 (RAEB-2) (62) - Go to question 214
☐ Refractory cytopenia with multilineage dysplasia (RCMD) (64) - Go to question 214
☐ Childhood myelodysplastic syndrome (Refractory cytopenia of childhood (RCC)) (68)

- Go to question 214

☐ Myelodysplastic syndrome with isolated del(5q) (5q– syndrome) (66) - Go to question 214
☐ Myelodysplastic syndrome (MDS), unclassifiable (50) - Go to question 214
☐ Chronic neutrophilic leukemia (165) - Go to question 214
☐ Chronic eosinophilic leukemia, NOS (166) - Go to question 214
☐ Essential thrombocythemia (includes primary thrombocytosis, idiopathic thrombocytosis, hemorrhagic

thrombocythemia) (58) - Go to question 214

☐ Polycythemia vera (PCV) (57) - Go to question 214
☐ Primary myelofibrosis (includes chronic idiopathic myelofibrosis (CIMF), angiogenic myeloid metaplasia

(AMM), myelofibrosis / sclerosis with myeloid metaplasia (MMM), idiopathic myelofibrosis) (167)

- Go to question 214

☐ Myeloproliferative neoplasm (MPN), unclassifiable (60) - Go to question 214
☐ Chronic myelomonocytic leukemia (CMMoL) (54) - Go to question 214
☐ Myelodysplastic / myeloproliferative neoplasm, unclassifiable (69) - Go to question 214
☐ Transformed to AML (70) - Go to question 215
214. Specify the date of the most recent transformation:

___ ___ ___ ___/ ___ ___ / ___ ___ - Go to question 216

YYYY
MM
DD

215. Date of MDS diagnosis:___ ___ ___ ___/ ___ ___ / ___ ___ - Go to signature line

YYYY
MM
DD

CIBMTR Form 2402 revision 2 (page 26 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Laboratory studies at last evaluation prior to the start of the preparative regimen:
216. WBC

☐ Known
☐ Unknown

217. ___ ___ ___ ___ ___ ___ ● ___

☐ x 10 /L (x 10 /mm )
9

3

3

☐ x 10 /L
6

218. Hemoglobin

☐ Known
☐ Unknown

☐ mmol/L
220. Was RBC transfused ≤ 30 days before date of test? ☐ Yes
☐ No
219. ___ ___ ___ ___ ● ___ ___

☐ g/dL

☐ g/L

221. Platelets

☐ Known
☐ Unknown

222. ___ ___ ___ ___ ___ ___ ___ ☐ x 109/L (x 103/mm3)

☐ x 10 /L
6

223. Were platelets transfused ≤ 7 days before date of test?

☐ Yes

☐ No

224. Neutrophils

☐ Known
☐ Unknown

225. ___ ___%

226. Blasts in bone marrow

☐ Known
☐ Unknown

227. ___ ___ ___ %

228. Were cytogenetics tested (karyotyping or FISH)?

☐ Yes
☐ No
☐ Unknown

229. Results of tests:

☐ Abnormalities identified
☐ No evaluable metaphases

☐ No abnormalities

Specify cytogenetic abnormalities identified at last evaluation prior to the start of the
preparative regimen:
230. Specify number of distinct cytogenetic abnormalities:

☐ One (1)
☐ Two (2)
☐ Three (3)

☐ Four or more (4 or more)

Monosomy
231. –5
232. –7
233. –13
234. –20
235. –Y
Trisomy
236. +8

CIBMTR Form 2402 revision 2 (page 27 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes

☐ No
☐ No
☐ No
☐ No
☐ No

☐ Yes

☐ No

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

☐ Yes

☐ No

☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes

☐ No
☐ No
☐ No
☐ No
☐ No
☐ No

☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes

☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No

☐ Yes

☐ No

253. i17q

☐ Yes

☐ No

254. Other abnormality

237. +19
Translocation
238. t(1;3)
239. t(2;11)
240. t(3;3)
241. t(3;21)
242. t(6;9)
243. t(11;16)
Deletion
244. del(3q) / 3q-
245. del(5q) / 5q-
246. del(7q) / 7q-
247. del(9q) / 9q-
248. del(11q) / 11q-
249. del(12p) / 12p-
250. del(13q) / 13q-
251. del(20q) / 20q-
Inversion
252. inv(3)
Other

☐ Yes
255. Specify other abnormality:____________________________
☐ No

Status at Transplantation:
256. 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 260

☐ 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 pre-treatment platelet count of < 20 x 109/L, platelet absolute increase of ≥ 20 x 109/L and ≥
100% from pre-treatment level * HI-N – neutrophil count increase of ≥ 100% from pre-treatment level and an absolute increase of
≥ 500/mm3 - Go to question 257

☐ No response (NR)/stable disease (SD) – does not meet the criteria for at least HI, but no evidence of disease progression

- Go to question 260

☐ 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 258

☐ Relapse from complete remission (Rel from CR) – requires at least one of the following: * return to pre-treatment bone marrow blast
percentage * decrease of ≥ 50% from maximum response levels in granulocytes or platelets * transfusion dependence, or
hemoglobin level ≥ 1.5 g/dL lower than prior to therapy - Go to question 259

☐ Not assessed - Go to signature line

CIBMTR Form 2402 revision 2 (page 28 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

257. Specify the cell line examined to determine HI status

☐ HI-E – hemoglobin increase of ≥ 1.5 g/dL untransfused; for RBC transfusions performed for Hgb

≤ 9.0, reduction in RBC units transfused in 8 weeks by ≥ 4 units compared to the pre-treatment
transfusion number in 8 weeks - Go to question 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
258. Date of progression: ___ ___ ___ ___/ ___ ___ / ___ ___ - Go to question 260

YYYY
MM
DD

259. Date of relapse: ___ ___ ___ ___ / ___ ___ / ___ ___ - Go to question 260
YYYY
MM
DD

260. Date assessed: ___ ___ ___ ___ / ___ ___ / ___ ___ - Go to signature line

YYYY
MM
DD

CIBMTR Form 2402 revision 2 (page 29 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Other Leukemia (OL)
261. Specify the other leukemia classification:

☐ Chronic lymphocytic leukemia (CLL), NOS (34) - Go to question 263

☐ Chronic lymphocytic leukemia (CLL), B-cell / small lymphocytic lymphoma (SLL) (71) - Go to question 263
☐ Hairy cell leukemia (35) - Go to question 266
☐ Hairy cell leukemia variant (75) - Go to question 266
☐ Monoclonal B-cell lymphocytosis (76) - Go to signature line
☐ Prolymphocytic leukemia (PLL), NOS (37) - Go to question 263
☐ PLL, B-cell (73) - Go to question 263
☐ PLL, T-cell (74) - Go to question 263
☐ Other leukemia, NOS (30) - Go to question 265
☐ Other leukemia (39) - Go to question 262
262. Specify other leukemia:___________________________________________________ - Go to question 265
263. Was any 17p abnormality detected?

☐ Yes - If disease classification is CLL, go to question 264.
☐ No

If PLL, go to question 266.

264. Did a histologic transformation to diffuse large B-cell lymphoma (Richter syndrome) occur at any time after

CLL diagnosis?

☐ Yes - Go to question 271 – Also complete NHL Disease Classification questions

☐ No - Go to question 266
Status at transplantation:
265. What was the disease status? (Atypical CML)

☐ Primary induction failure - Go to question 267
☐ 1 complete remission (no previous bone marrow or extramedullary relapse) - Go to question 267
☐ 2 complete remission - Go to question 267
☐ ≥ 3 complete remission - Go to question 267
☐ 1 relapse - Go to question 267
☐ 2 relapse - Go to question 267
☐ ≥ 3 relapse - Go to question 267
☐ No treatment - Go to signature line

st

nd

rd

st

nd

rd

266. What was the disease status? (CLL, PLL, Hairy cell leukemia)

☐ Complete remission (CR) - Go to question 267
☐ Partial remission (PR) - Go to question 267
☐ Stable disease (SD) - Go to question 267
☐ Progressive disease (Prog) - Go to question 267
☐ Untreated - Go to question 267
☐ Not assessed - Go to signature line

267. Date assessed: __ __ __ __ / __ __ / __ __ - Go to signature line

YYYY
MM
DD

CIBMTR Form 2402 revision 2 (page 30 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Hodgkin Lymphoma
268. Specify Hodgkin lymphoma classification:

☐ Nodular lymphocyte predominant Hodgkin Lymphoma (155)
☐ Lymphocyte-rich (151)
☐ Nodular sclerosis (152)
☐ Mixed cellularity (153)
☐ Lymphocyte depleted (154)
☐ Hodgkin Lymphoma, NOS (150)

Status at transplantation:
269. 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 - 1 complete remission: no bone marrow or extramedullary relapse prior to transplant
☐ CR2 - 2 complete remission
☐ CR3+ - 3 or subsequent complete remission
☐ REL1 unt - 1 relapse – untreated; includes either bone marrow or extramedullary relapse
☐ REL1 res - 1 relapse – resistant: stable or progressive disease with treatment
☐ REL1 sen - 1 relapse – sensitive: partial remission (if complete remission was achieved, classify as CR2)
☐ REL1 unk - 1 relapse – sensitivity unknown
☐ REL2 unt - 2 relapse – untreated: includes either bone marrow or extramedullary relapse
☐
REL2 res - 2 relapse – resistant: stable or progressive disease with treatment
☐ REL2 sen - 2 relapse – sensitive: partial remission (if complete remission achieved, classify as CR3+)
☐ REL2 unk - 2 relapse – sensitivity unknown
☐ REL3+ unt - 3 or subsequent relapse – untreated; includes either bone marrow or extramedullary relapse
☐ REL3+ res - 3 or subsequent relapse – resistant: stable or progressive disease with treatment
☐ REL3+ sen - 3 or subsequent relapse – sensitive: partial remission (if complete remission achieved, classify as CR3+)
☐
REL3+ unk - 3 relapse or greater – sensitivity unknown

st

nd

rd

st

st

st
st

nd

nd

nd
nd

rd

rd

rd

rd

270. Date assessed: __ __ __ __ / __ __ / __ __ - Go to signature line
YYYY

MM

DD

CIBMTR Form 2402 revision 2 (page 31 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Non-Hodgkin Lymphoma
271. Specify Non-Hodgkin lymphoma classification:

☐ Splenic marginal zone B-cell lymphoma (124)
☐ Extranodal marginal zone B-cell lymphoma of mucosal associated lymphoid tissue type (MALT) (122)
☐ Nodal marginal zone B-cell lymphoma (± monocytoid B-cells) (123)
☐ Follicular, predominantly small cleaved cell (Grade I follicle center lymphoma) (102)
☐ Follicular, mixed, small cleaved and large cell (Grade II follicle center lymphoma) (103)
☐ Follicular, predominantly large cell (Grade IIIA follicle center lymphoma) (162)
☐ Follicular, predominantly large cell (Grade IIIB follicle center lymphoma) (163)
☐ Follicular (grade unknown) (164)
☐ Mantle cell lymphoma (115)
☐ Intravascular large B-cell lymphoma (136)
☐ Primary mediastinal (thymic) large B-cell lymphoma (125)
☐ Primary effusion lymphoma (138)
☐ Diffuse, large B-cell lymphoma — NOS (107)
☐ Burkitt lymphoma (111)
☐ B-cell lymphoma, unclassifiable, with features intermediate between DLBCL and Burkitt lymphoma (140)
☐ B-cell lymphoma, unclassifiable, with features intermediate between DLBCL and classical Hodgkin Lymphoma (149)
☐ T-cell / histiocytic rich large B-cell lymphoma (120)
☐ Primary diffuse large B-cell lymphoma of the CNS (118)
☐ Waldenstrom macroglobulinemia / Lymphoplasmacytic lymphoma (173)
☐ Other B-cell lymphoma (129) - Go to question 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)

272. Specify other lymphoma: _______________________________

273. Is the non-Hodgkin lymphoma histology reported at diagnosis a transformation from CLL?

☐ Yes - Go to question 275 – Also complete CLL Disease Classification questions
☐ No

274. Is the non-Hodgkin lymphoma histology reported a transformation from, or was it diagnosed at the same time

as another lymphoma (not CLL)?

CIBMTR Form 2402 revision 2 (page 32 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

☐ Yes

☐ No

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Status at transplantation:
275. 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

276. Date assessed: __ __ __ __ / __ __ / __ __ - Go to signature line

YYYY
MM
DD

CIBMTR Form 2402 revision 2 (page 33 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Multiple Myeloma / Plasma Cell Disorder (PCD)
277. Specify the multiple myeloma / plasma cell disorder (PCD) classification:

☐ Multiple myeloma-lgG (181) - Go to questions 279

☐ Multiple myeloma-lgA (182) - Go to questions 279

☐ Multiple myeloma-lgD (183) - Go to questions 279

☐ Multiple myeloma-lgE (184) - Go to questions 279

☐ Multiple myeloma-lgM (not Waldenstrom macroglobulinemia) (185) - Go to questions 279
☐ Multiple myeloma-light chain only (186) - Go to questions 279
☐ Multiple myeloma-non-secretory (187) - Go to questions 280
☐ Plasma cell leukemia (172) - Go to question 285
☐ Solitary plasmacytoma (no evidence of myeloma) (175) - Go to question 285
☐ Amyloidosis (174) - Go to question 285
☐ Osteosclerotic myeloma / POEMS syndrome (176) - Go to question 285
☐ Light chain deposition disease (177) - Go to question 285

☐ Other plasma cell disorder (179) - Go to question 278

278. Specify other plasma cell disorder:_________________________________________________________

- Go to question 285
279. Light chain

☐ kappa

☐ lambda

280. 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 281

☐ Stage II (Fitting neither Stage I or Stage III) - Go to questions 281

☐ 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 281

☐ Unknown - Go to questions 282

281. 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.:
282. Serum β2-microglobulin: ___ ___ ___ ● ___ ___ ___
283. Serum albumin: ___ ___ ● ___

☐ g/dL ☐ g/L

284. Stage

☐ 1 (β -mic < 3.5, S. albumin > 3.5)
☐ 2 (Not fitting stage 1 or 3)
☐ 3 (β -mic ≥ 5.5; S. albumin -)
2

2

CIBMTR Form 2402 revision 2 (page 34 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

☐ μg/dL ☐ mg/L

☐ nmol/L

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

285. Were cytogenetics tested (karyotyping or FISH)?

☐ Yes
☐ No
☐ Unknown

286. Results of tests:

☐ Abnormalities identified
☐ No evaluable metaphases

☐ No abnormalities

Specify cytogenetic abnormalities identified at any time prior to the start of the
preparative regimen:

Trisomy

☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes

287. +3
288. +5
289. +7
290. +9
291. +11
292. +15
293. +19

☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No

Translocation
294. t(4;14)
295. t(6;14)
296. t(11;14)
297. t(14;16)
298. t(14;20)
Deletion
299. del(13q) / 13q-
300. del 17 / 17p-
Other
301. Hyperdiploid (>50)
302. Hypodiploid (<46)
303. Any abnormality at 1q
304. Any abnormality at 1p

☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes

☐ No
☐ No
☐ No
☐ No
☐ No

☐ Yes
☐ Yes

☐ No
☐ No

☐ Yes
☐ Yes
☐ Yes
☐ Yes

☐ No
☐ No
☐ No
☐ No

305. Other abnormality

☐ Yes
☐ No

CIBMTR Form 2402 revision 2 (page 35 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

306. Specify other abnormality:____________________________

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Status at transplantation:
307. 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 questions 308

☐ 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 questions 308

☐ 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 questions 308

☐ 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 questions 308

☐ 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 questions 308

☐ 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 questions 308

☐ Progressive disease (PD) – requires any one or more of the following: Increase of ≥ 25% from baseline in: serum M-component

and/or (absolute increase ≥ 0.5 g/dL) (for progressive disease, serum M-component increases of ≥ 1 g/dL are sufficient to define

relapse if the starting M-component is ≥ 5 g/dL). Urine M-component and/or (absolute increase ≥ 200 mg/24 hours) for recipients

without measurable serum and urine M-protein levels: the difference between involved and uninvolved free light chain levels

(absolute increase > 10 mg/dL). Bone marrow plasma cell percentage (absolute percentage ≥ 10%) (relapse from CR has a 5%

cutoff vs. 10% for other categories of relapse) definite development of new bone lesions or soft tissue plasmacytomas, or

definite increase in the size of any existing bone lesions 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 questions 308

☐ 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 questions 308

☐ Unknown - signature line
☐ Not applicable – (Amyloidosis with no evidence of myeloma) - Go to signature line

308. Date assessed: __ __ __ __ / __ __ / __ __ - Go to signature line
YYYY
MM
DD

CIBMTR Form 2402 revision 2 (page 36 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Solid Tumors
309. 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)
☐ Prostate (209)
☐ External genitalia (211)
☐ Cervical (212)
☐ Uterine (213)
☐ Vaginal (215)
☐ Melanoma (219)
☐ Wilm tumor (221)
☐ Retinoblastoma (223)
☐ Thymoma (231)
☐ Renal cell (208)
☐ Other solid tumor (269)
☐ Solid tumor, not otherwise specified (200)

- Go to signature line

CIBMTR Form 2402 revision 2 (page 37 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

310. Specify other solid tumor:_______________________________

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Severe Aplastic Anemia
311. 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 signature line

CIBMTR Form 2402 revision 2 (page 38 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

312. Specify other acquired cytopenic syndrome:_________________

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Inherited Abnormalities of Erythrocyte Differentiation or Function
313. Specify the inherited abnormalities of erythrocyte differentiation or function classification

☐ Paroxysmal nocturnal hemoglobinuria (PNH) (56)
☐ Shwachman-Diamond (305)
☐ Diamond-Blackfan anemia (pure red cell aplasia) (312)
☐ Other constitutional anemia (319)
☐ 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 signature line

314. Specify other constitutional anemia:_______________________

CIBMTR Form 2402 revision 2 (page 39 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

315. Specify other hemoglobinopathy:_________________________

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Disorders of the Immune System
316. 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)
317. Specify other SCID:____________________________________
☐ 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)
☐ Cartilage-hair hypoplasia (462)
☐ CD40 ligand deficiency (464)
☐ Other immunodeficiencies (479)
318. Specify other immunodeficiency:__________________________
☐ Immune deficiency, not otherwise specified (400)
☐ Chediak-Higashi syndrome (456)
☐ Griscelli syndrome type 2 (465)
☐ Hermansky-Pudlak syndrome type 2 (466)
☐ Chronic granulomatous disease (455)
☐ Wiskott-Aldrich syndrome (453)
☐ X-linked lymphoproliferative syndrome (458)

- Go to signature line

CIBMTR Form 2402 revision 2 (page 40 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Inherited Abnormalities of Platelets
319. Specify inherited abnormalities of platelets classification

☐ Congenital amegakaryocytosis / congenital thrombocytopenia (501)
☐ Glanzmann thrombasthenia (502)
☐ Other inherited platelet abnormality (509)

- Go to signature line

CIBMTR Form 2402 revision 2 (page 41 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

320. Specify other inherited platelet abnormality:_________________

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Inherited Disorders of Metabolism
321. Specify inherited disorders of metabolism classification

☐ Osteopetrosis (malignant infantile osteopetrosis) (521)

Leukodystrophies

☐ Metachromatic leukodystrophy (MLD) (542)
☐ Adrenoleukodystrophy (ALD) (543)
☐ Krabbe disease (globoid leukodystrophy) (544)
☐ Lesch-Nyhan (HGPRT deficiency) (522)
☐ Neuronal ceroid lipofuscinosis (Batten disease) (523)

Mucopolysaccharidoses

☐ Hurler syndrome (IH) (531)
☐ Scheie syndrome (IS) (532)
☐ Hunter syndrome (II) (533)
☐ Sanfilippo (III) (534)
☐ Morquio (IV) (535)
☐ Maroteaux-Lamy (VI) (536)
☐ 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)
322.
☐ Inherited metabolic disorder, not otherwise specified (520)

- Go to signature line

CIBMTR Form 2402 revision 2 (page 42 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

Specify other inherited metabolic disorder:__________________

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Histiocytic disorders
323. Specify histiocytic disorder classification

☐ Hemophagocytic lymphohistiocytosis (HLH) (571)
☐ Langerhans cell histiocytosis (histiocytosis-X) (572)
☐ Hemophagocytosis (reactive or viral associated) (573)
☐ Malignant histiocytosis (574)
☐ Other histiocytic disorder (579)
☐ Histiocytic disorder, not otherwise specified (570)

- Go to signature line

CIBMTR Form 2402 revision 2 (page 43 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

324. Specify other histiocytic disorder:_________________________

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Autoimmune Diseases
325. 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)
326.
☐ Juvenile idiopathic arthritis (JIA): other (643)
☐ Other arthritis (633)

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)

Vasculitis

☐ Wegener granulomatosis (610)
☐ Classical polyarteritis nodosa (631)
☐ Microscopic polyarteritis nodosa (632)
☐ Churg-Strauss (635)
☐ Giant cell arteritis (636)
☐ Takayasu (637)
☐ Behcet syndrome (638)
☐ Overlap necrotizing arteritis (639)
☐ Other vasculitis (611)

Other neurological autoimmune diseases

☐ Myasthenia gravis (601)
☐ Other autoimmune neurological disorder (644)

Hematological autoimmune diseases

☐ Idiopathic thrombocytopenic purpura (ITP) (645)
☐ Hemolytic anemia (646)
☐ Evan syndrome (647)
☐ Other autoimmune cytopenia (648)

Bowel diseases

☐ Crohn’s disease (649)
☐ Ulcerative colitis (650)
☐ Other autoimmune bowel disorder (651)
- Go to signature line

CIBMTR Form 2402 revision 2 (page 44 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

Specify other juvenile idiopathic arthritis (JIA):_______________

327. Specify other arthritis:__________________________________

328. Specify other connective tissue disease:____________________

329. Specify other vasculitis:_________________________________

330. Specify other autoimmune neurological disorder:_____________

331. Specify other autoimmune cytopenia:______________________

332. Specify other autoimmune bowel disorder:__________________

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Other Disease
333. Specify other disease:____________________________________________________

First Name:_____________________________________________________
Last Name:______________________________________________________
E-mail address:__________________________________________________
Date: __ __ __ __ / __ __ / __ __
YYYY
MM
DD

CIBMTR Form 2402 revision 2 (page 45 of 45). Last Updated July, 2017.
Copyright (c) 2017 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.