17 Post Transplant Malignancy Form_All Organs.xlsx

Data System for Organ Procurement and Transplantation Network

Post Transplant Malignancy Form_All Organs.xlsx

Lung - Post Transplant Malignancy (PTM) Form

OMB: 0915-0157

Document [xlsx]
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Post Transplant Malignancy Form (PTM) - All Organs

Fields to be completed by members





Form Section Field Label Notes

1-Recipient Information Recipient last name Display Only - Cascades from Database

1-Recipient Information Recipient first name Display Only - Cascades from Database

1-Recipient Information Recipient Middle Initial Not required

1-Recipient Information Date of birth Display Only - Cascades from Database

1-Recipient Information Recipient SSN Display Only - Cascades from Database

1-Recipient Information Recipient organ Display Only - Cascades from Database

1-Recipient Information TRF Display Only - Cascades from Database

1-Recipient Information Follow-up code Display Only - Cascades from Database

1-Recipient Information Transplant date Display Only - Cascades from Database

1-Recipient Information Follow-up Center Code Display Only - Cascades from Database

1-Recipient Information Follow-up Center Type Display Only - Cascades from Database

1-Recipient Information Followup Center Display Only - Cascades from Database

1-Recipient Information Transplant Center Code Display Only - Cascades from Database

1-Recipient Information Transplant Center Type Display Only - Cascades from Database

1-Recipient Information Transplant Center Display Only - Cascades from Database

2-Donor Related Diagnosis date:

2-Donor Related Tumor type:

2-Donor Related Tumor Types: Skin: //squamous cell:

2-Donor Related Tumor Types: Skin: //basal cell:

2-Donor Related Tumor Types: Skin: //melanoma:

2-Donor Related Tumor Types: //Kaposi's sarcoma: cutaneous:

2-Donor Related Tumor Types: //Kaposi's sarcoma: visceral:

2-Donor Related Tumor Types: //Brain:

2-Donor Related Tumor Types: Brain: //Other specify:

2-Donor Related Tumor Types: //Renal carcinoma - specify site(s):

2-Donor Related Tumor Types: //Carcinoma of vulva, perineum or penis, scrotum:

2-Donor Related Tumor Types: //Carcinoma of the uterus:

2-Donor Related Tumor Types: //Ovarian:

2-Donor Related Tumor Types: //Testicular:

2-Donor Related Tumor Types: //Esophagus:

2-Donor Related Tumor Types: //Stomach:

2-Donor Related Tumor Types: //Small intestine:

2-Donor Related Tumor Types: //Pancreas:

2-Donor Related Tumor Types: //Larynx:

2-Donor Related Tumor Types: //Tongue, throat:

2-Donor Related Tumor Types: //Thyroid:

2-Donor Related Tumor Types: //Bladder:

2-Donor Related Tumor Types: //Breast:

2-Donor Related Tumor Types: //Prostate:

2-Donor Related Tumor Types: //Colo-rectal:

2-Donor Related Tumor Types: //Primary hepatic tumor:

2-Donor Related Tumor Types: //Metastatic liver tumor:

2-Donor Related Tumor Types: //Lung:

2-Donor Related Tumor Types://Leukemia:

2-Donor Related Tumor Types: //Sarcomas:

2-Donor Related Tumor Types: //Other cancers:

2-Donor Related Other Cancers: //Site(s):

2-Donor Related Tumor Types: //Primary unknown:

3-Recurrence of Pretransplant Malignancy Type of pre-existing tumor:

3-Recurrence of Pretransplant Malignancy If other cancer, specify:

3-Recurrence of Pretransplant Malignancy Date of recurrence (post tx):

4-Post Transplant De Novo Solid Tumor Tumor Types: Skin: //squamous cell:

4-Post Transplant De Novo Solid Tumor Tumor Types: Skin: //basal cell:

4-Post Transplant De Novo Solid Tumor Tumor Types: Skin: //melanoma:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Kaposi's sarcoma: cutaneous:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Kaposi's sarcoma: visceral:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Brain:

4-Post Transplant De Novo Solid Tumor Tumor Types: Brain: //Other specify:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Renal carcinoma - specify site(s):

4-Post Transplant De Novo Solid Tumor Tumor Types: //Carcinoma of vulva, perineum or penis, scrotum:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Carcinoma of the uterus:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Ovarian:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Testicular:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Esophagus:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Stomach:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Small intestine:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Pancreas:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Larynx:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Tongue, throat:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Thyroid:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Bladder:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Breast:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Prostate:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Colo-rectal:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Primary hepatic tumor:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Metastatic liver tumor:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Lung:

4-Post Transplant De Novo Solid Tumor Tumor Types://Leukemia:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Sarcomas:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Other cancers:

4-Post Transplant De Novo Solid Tumor Other Cancers: //Site(s):

4-Post Transplant De Novo Solid Tumor Tumor Types: //Primary unknown:

4-Post Transplant De Novo Solid Tumor Diagnosis date

5-Post Transplant Lymphoproliferative Disease and Lymphoma PTLD: //Diagnosis date:

5-Post Transplant Lymphoproliferative Disease and Lymphoma PTLD: //Pathology:

5-Post Transplant Lymphoproliferative Disease and Lymphoma PTLD: Pathology: //Other Specify:






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