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pdfDisease 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
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Expiration date: 1/31/2020
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Event date: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
CIBMTR Form 2402 revision 4 (page 1 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 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 96
☐ Acute leukemia of ambiguous lineage and other myeloid neoplasms (80) - Go to question 164
☐ Chronic myelogenous leukemia (CML) (40) - Go to question 168
☐ 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 179
- Go to question 271
☐ Other leukemia (30) (includes CLL) - Go to question 229
☐ Hodgkin lymphoma (150) - Go to question 236
☐ Non-Hodgkin lymphoma (100) - Go to question 236
☐ Multiple myeloma / plasma cell disorder (PCD) (170) - Go to question 254
☐ Solid tumors (200) - Go to question 269
☐ 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 273
☐ Disorders of the immune system (400) - Go to question 307
☐ Inherited abnormalities of platelets (500) - Go to question 314
☐ Inherited disorders of metabolism (520) - Go to question 316
☐ Histiocytic disorders (570) - Go to question 319
☐ Autoimmune diseases (600) - Go to question 324
☐ Tolerance induction associated with solid organ transplant - Go to question 327
☐ Recessive Dystrophic Epidermolysis Bullosa - Go to signature line
☐ Other disease (900) - Go to question 329
CIBMTR Form 2402 revision 4 (page 2 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
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)
AML, not otherwise specified
4.
Did AML transform from MDS or MPN?
5.
Is the disease (AML) therapy related?
☐ 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)
6.
☐ Yes – Also complete MDS Disease Classification questions ☐ No
☐ Yes ☐ No ☐ Unknown
Did the recipient have a predisposing condition?
☐ Yes
☐ No
☐ Unknown
7.
Specify condition:
☐ Bloom syndrome
☐ Down syndrome
☐ Fanconi anemia – Also complete CIBMTR Form 2029
☐ Dyskeratosis congenita
☐ Other condition
8.
Specify other condition:_____________________________
CIBMTR Form 2402 revision 4 (page 3 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
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.
13.
International System for Human Cytogenetic Nomenclature
(ISCN) compatible string:______________________________
14.
Specify abnormalities (check all that apply)
Specify number of distinct cytogenetic abnormalities:
☐ 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–
CIBMTR Form 2402 revision 4 (page 4 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
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
15. Specify other abnormality:
________________________
16. Were cytogenetics tested via karyotyping?
☐ Yes
☐ No
17. Results of tests:
☐ Abnormalities identified
☐ No evaluable metaphases
☐ No abnormalities
Specify cytogenetic abnormalities identified at diagnosis:
18.
19.
International System for Human Cytogenetic Nomenclature
(ISCN) compatible string:_____________________________
20.
Specify abnormalities: (check all that apply)
Specify number of distinct cytogenetic abnormalities:
☐ One (1)
☐ Two (2)
☐ Three (3)
☐ Four or more (4 or more)
☐ -5
☐ -7
☐ -17
☐ -18
☐ -X
☐ -Y
☐ +4
☐ +8
☐ +11
☐ +13
☐ +14
☐ +21
CIBMTR Form 2402 revision 4 (page 5 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ +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
21. Specify other abnormality:
________________________
22. Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)
☐ Yes
☐ No
23. Were tests for molecular markers performed (e.g. PCR, NGS)? (at diagnosis)
☐ Yes
☐ No
☐ Unknown
Specify molecular markers identified at diagnosis:
24. CEBPA
☐ Positive
☐ Negative
☐ Not done
25. Specify CEBPA mutation
☐ Biallelic (homozygous)
☐ Monoallelic (heterozygous)
☐ Unknown
☐ Positive
26. FLT3 – D835 point mutation
☐ Negative
☐ Not done
27. FLT3 – ITD mutation
☐ Positive
☐ Negative
☐ Not done
28. FLT3 – ITD allelic ratio
☐ Known
☐ Unknown
29. Specify FLT3 - ITD allelic ratio:
___ ● ___
CIBMTR Form 2402 revision 4 (page 6 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ Positive
☐ Positive
☐ Positive
☐ Positive
30. IDH1
31. IDH2
32. KIT
33. NPM1
☐ Negative
☐ Negative
☐ Negative
☐ Negative
☐ Not done
☐ Not done
☐ Not done
☐ Not done
34. Other molecular marker
☐ Positive
35. Specify other molecular marker:________________________
☐ Negative
☐ Not done
Copy and complete questions 34-35 for multiple molecular markers.
Labs between diagnosis and last evaluation:
36. Were cytogenetics tested (karyotyping or FISH)? (between diagnosis and last evaluation)
☐ Yes
☐ No
☐ Unknown
37.
Were cytogenetics tested via FISH?
☐ Yes
☐ No
38.
Results of tests:
☐ Abnormalities identified
☐ No abnormalities
Specify cytogenetic abnormalities identified between diagnosis
and last evaluation:
39.
40.
International System for Human Cytogenetic Nomenclature
(ISCN) compatible string:_____________________________
41.
Specify abnormalities (check all that apply)
Specify number of distinct cytogenetic abnormalities:
☐ 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)
CIBMTR Form 2402 revision 4 (page 7 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ 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
42. Specify other abnormality:
________________________
CIBMTR Form 2402 revision 4 (page 8 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
43. Were cytogenetics tested via karyotyping?
☐ Yes
☐ No
44.
Results of tests:
☐ Abnormalities identified
☐ No evaluable metaphases
☐ No abnormalities
Specify cytogenetic abnormalities identified between diagnosis
and last evaluation:
45.
International System for Human Cytogenetic Nomenclature
(ISCN) compatible string:_____________________________
46.
Specify number of distinct cytogenetic abnormalities:
47.
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 4 (page 9 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 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
48. Specify other abnormality:
________________________
49. Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)
☐ Yes
☐ No
50. Were tests for molecular markers performed (e.g. PCR, NGS)? (between diagnosis and last evaluation)
☐ Yes
☐ No
☐ Unknown
Specify molecular markers identified between diagnosis:
51. CEBPA
☐ Positive
☐ Negative
☐ Not done
52. Specify CEBPA mutation
☐ Biallelic (homozygous)
☐ Monoallelic (heterozygous)
☐ Unknown
☐ Positive
53. FLT3 – D835 point mutation
☐ Negative
☐ Not done
54. FLT3 – ITD mutation
☐ Positive
☐ Negative
☐ Not done
57. IDH1
58. IDH2
59. KIT
60. NPM1
55. FLT3 – ITD allelic ratio
☐ Known
☐ Unknown
56. Specify FLT3 - ITD allelic ratio:
___ ● ___
☐ Positive
☐ Positive
☐ Positive
☐ Positive
☐ Negative
☐ Negative
☐ Negative
☐ Negative
61. Other molecular marker
☐ Not done
☐ Not done
☐ Not done
☐ Not done
☐ Positive
62. Specify other molecular marker:_________________________
☐ Negative
☐ Not done
Copy and complete questions 61-62 to report multiple other molecular markers.
CIBMTR Form 2402 revision 4 (page 10 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Labs at last evaluation:
63. Were cytogenetics tested (karyotyping or FISH)? (at last evaluation)
☐ Yes
☐ No
☐ Unknown
64. Were cytogenetics tested via FISH?
☐ Yes
☐ No
65.
Results of tests:
☐ Abnormalities identified
☐ No abnormalities
Specify cytogenetic abnormalities identified at last evaluation:
66. International System for Human Cytogenetic Nomenclature
(ISCN) compatible string:_____________________________
67. Specify number of distinct cytogenetic abnormalities:
☐ One (1)
☐ Two (2)
☐ Three (3)
☐ Four or more (4 or more)
68. 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 4 (page 11 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
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
69. Specify other abnormality:
70.
________________________
Were cytogenetics tested via karyotyping?
☐ Yes
☐ No
71.
Results of tests:
☐ Abnormalities identified
☐ No evaluable metaphases
☐ No abnormalities
Specify cytogenetic abnormalities identified at last evaluation:
72. International System for Human Cytogenetic Nomenclature
(ISCN) compatible string:_____________________________
73. Specify number of distinct cytogenetic abnormalities:
☐ One (1)
☐ Two (2)
☐ Three (3)
☐ Four or more (4 or more)
74. Specify abnormalities (check all that apply)
☐ -5
☐ -7
☐ -17
☐ -18
☐ -X
☐ -Y
☐ +4
☐ +8
☐ +11
☐ +13
☐ +14
☐ +21
☐ +22
CIBMTR Form 2402 revision 4 (page 12 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
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
75. Specify other abnormality:
________________________
76. Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)
☐ Yes
☐ No
77. Were tests for molecular markers performed (e.g. PCR, NGS)? (at last evaluation)
☐ Yes
☐ No
☐ Unknown
Specify molecular markers identified at last evaluation:
78. CEBPA
☐ Positive
☐ Negative
☐ Not done
79. Specify CEBPA mutation
☐ Biallelic (homozygous)
☐ Monoallelic (heterozygous)
☐ Unknown
☐ Positive
80. FLT3 – D835 point mutation
☐ Negative
☐ Not done
81. FLT3 – ITD mutation
☐ Positive
☐ Negative
☐ Not done
82. FLT3 – ITD allelic ratio
☐ Known
☐ Unknown
83. Specify FLT3 - ITD allelic ratio:
___ ● ___
CIBMTR Form 2402 revision 4 (page 13 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ Positive
☐ Positive
☐ Positive
☐ Positive
84. IDH1
85. IDH2
86. KIT
87. NPM1
☐ Negative
☐ Negative
☐ Negative
☐ Negative
☐ Not done
☐ Not done
☐ Not done
☐ Not done
88. Other molecular marker
☐ Positive
☐ Negative
89. Specify other molecular marker:_________________________
☐ Not done
Copy and complete questions 88-89 to report multiple other molecular markers.
CNS Leukemia
90. 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:
91. What was the disease status (based on hematological test results)?
☐ Primary induction failure - Go to question 95
☐ 1st complete remission (no previous bone marrow or
extramedullary relapse) (include CRi)
- Go to question 92
☐ 2nd complete remission - Go to question 92
☐ ≥ 3rd complete remission - Go to question 92
92. How many cycles of induction therapy were required to achieve
1st complete remission? (includes CRi)
☐ 1 ☐ 2 ☐ ≥ 3
93. Was the recipient in remission by flow cytometry?
☐ Yes
☐ 1st relapse - Go to question 94
☐ 2nd relapse - Go to question 94
☐ ≥ 3rd relapse - Go to question 94
☐ No treatment - Go to question 95
☐ No ☐ Unknown
☐ Not applicable
- Go to question 95
94. Date of most recent relapse:__ __ __ __ / __ __ / __ __
YYYY
MM
DD
95. Date assessed: __ __ __ __ / __ __ / __ __ - Go to signature line
YYYY
MM
DD
CIBMTR Form 2402 revision 4 (page 14 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Acute Lymphoblastic Leukemia (ALL)
96. 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 (<46 chromosomes) (83)
☐ B-lymphoblastic leukemia / lymphoma, BCR-ABL1-like (provisional entity) (94)
☐ B-lymphoblastic leukemia / lymphoma, with iAMP21 (95)
T-cell lymphoblastic leukemia / lymphoma
NK cell lympoblastic leukemia/lymphoma
☐ T-cell lymphoblastic leukemia/lymphoma (Precursor T-cell ALL) (196)
☐ Early T-cell precursor lymphoblastic leukemia (96)
☐ Natural killer (NK)- cell lymphoblastic leukemia / lymphoma (97)
97. Did the recipient have a predisposing condition?
☐ Yes
☐ No
☐ Unknown
98. Specify condition:
☐ Aplastic anemia – Also complete CIBMTR Form 2028 — APL
☐ Bloom syndrome
☐ Down syndrome
☐ Fanconi anemia – Also complete CIBMTR Form 2029 — FAN
☐ Other condition
99.
Specify other condition:_______________________________
100. Were tyrosine kinase inhibitors given for therapy at any time prior to start of the preparative regimen / infusion?
(e.g. imatinib mesylate, dasatinib, etc.)
CIBMTR Form 2402 revision 4 (page 15 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
☐ Yes
☐ No
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Laboratory studies at diagnosis:
101. Were cytogenetics tested (karyotyping or FISH)? (at diagnosis)
☐ Yes
☐ No
☐ Unknown
102. Were cytogenetics tested via FISH? (at diagnosis)
☐ Yes
☐ No
103. Results of tests: (at diagnosis)
☐ Abnormalities identified
☐ No abnormalities
Specify cytogenetic abnormalities identified:
104. International System for Human Cytogenetic Nomenclature
(ISCN) compatible string:_____________________________
105. Specify number of distinct cytogenetic abnormalities:
☐ One (1)
☐ Two (2)
☐ Three (3)
☐ Four or more (4 or more)
106. 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 (< 46)
☐ iAMP21
☐ Other abnormality
107. Specify other
abnormality:
CIBMTR Form 2402 revision 4 (page 16 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
___________________
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
108. Were cytogenetics tested via karyotyping? (at diagnosis)
☐ Yes
☐ No
109. Results of tests: (at diagnosis)
☐ Abnormalities identified
☐ No evaluable metaphases
☐ No abnormalities
Specify cytogenetic abnormalities identified:
110. International System for Human Cytogenetic Nomenclature
(ISCN) compatible string:_____________________________
111. Specify number of distinct cytogenetic abnormalities:
☐ One (1)
☐ Two (2)
☐ Three (3)
☐ Four or more (4 or more)
112. 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 (< 46)
☐ iAMP21
☐ Other abnormality
113. Specify other
abnormality:
___________________
114. Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)
CIBMTR Form 2402 revision 4 (page 17 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
☐ Yes
☐ No
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
115. Were tests for molecular markers performed (e.g. PCR, NGS)? (at diagnosis)
☐ Yes
☐ No
☐ Unknown
Specify molecular markers identified at diagnosis:
☐ Positive
☐ Positive
116. BCR / ABL
117. TEL-AML / AML1
☐ Negative
☐ Negative
☐ Not done
☐ Not done
118. Other molecular marker
☐ Positive
119. Specify other molecular marker:_________________________
☐ Negative
☐ Not done
Copy and complete questions 118-119 for additional molecular markers
Laboratory studies between diagnosis and last evaluation:
120. Were cytogenetics tested (karyotyping or FISH)? (between diagnosis and last evaluation)
☐ Yes
☐ No
☐ Unknown
121. Were cytogenetics tested via FISH? (between diagnosis and the last evaluation)
☐ Yes
☐ No
122. Results of tests: (between diagnosis and the last evaluation)
☐ Abnormalities identified
☐ No abnormalities
Specify cytogenetic abnormalities identified:
123. International System for Human Cytogenetic Nomenclature
(ISCN) compatible string:_____________________________
124. Specify number of distinct cytogenetic abnormalities:
☐ One (1)
☐ Two (2)
☐ Three (3)
☐ Four or more (4 or more)
125. 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 4 (page 18 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 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 (< 46)
☐ iAMP21
☐ Other abnormality
126. Specify other
abnormality:
___________________
127. Were cytogenetics tested via karyotyping? (between diagnosis and the last evaluation)
☐ Yes
☐ No
128. Results of tests: (between diagnosis and the last evaluation)
☐ Abnormalities identified
☐ No evaluable metaphases
☐ No abnormalities
Specify cytogenetic abnormalities identified:
129. International System for Human Cytogenetic Nomenclature
(ISCN) compatible string:_____________________________
130. Specify number of distinct cytogenetic abnormalities:
☐ One (1)
☐ Two (2)
☐ Three (3)
☐ Four or more (4 or more)
131. 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)
CIBMTR Form 2402 revision 4 (page 19 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ 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 (< 46)
☐ iAMP21
☐ Other abnormality
132. Specify other abnormality:
_______________________
133. Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)
☐ Yes ☐ No
134. 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:
135. BCR / ABL
136. TEL-AML / AML1
☐ Positive
☐ Positive
137. Other molecular marker
☐ Negative
☐ Negative
☐ Not done
☐ Not done
☐ Positive
138. Specify other molecular marker:_______________________
☐ Negative
☐ Not done
Copy and complete questions 137-138 for additional molecular markers
CIBMTR Form 2402 revision 4 (page 20 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 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:
139. Were cytogenetics tested (karyotyping or FISH)? (at last evaluation)
☐ Yes
☐ No
☐ Unknown
140. Were cytogenetics tested via FISH?
☐ Yes
☐ No
141. Results of tests:
☐ Abnormalities identified
☐ No abnormalities
Specify cytogenetic abnormalities identified at last evaluation:
142. International System for Human Cytogenetic Nomenclature
(ISCN) compatible string:_____________________________
143. Specify number of distinct cytogenetic abnormalities:
☐ One (1)
☐ Two (2)
☐ Three (3)
☐ Four or more (4 or more)
144. 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 (< 46)
☐ iAMP21
☐ Other abnormality
145. Specify other
abnormality:
CIBMTR Form 2402 revision 4 (page 21 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
___________________
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
146. Were cytogenetics tested via karyotyping? (at last evaluation)
☐ Yes
☐ No
147. Results of tests:
☐ Abnormalities identified
☐ No evaluable metaphases
☐ No abnormalities
Specify cytogenetic abnormalities identified at last evaluation:
148. International System for Human Cytogenetic Nomenclature
(ISCN) compatible string:_____________________________
149. Specify number of distinct cytogenetic abnormalities:
☐ One (1)
☐ Two (2)
☐ Three (3)
☐ Four or more (4 or more)
150. 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 (< 46)
☐ iAMP21
☐ Other abnormality
151. Specify other
abnormality:
152. Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)
CIBMTR Form 2402 revision 4 (page 22 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
______________
☐ Yes
☐ No
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
153. 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
154. BCR / ABL
155. TEL-AML / AML1
☐ Negative
☐ Negative
☐ Not done
☐ Not done
156. Other molecular marker
☐ Positive
157. Specify other molecular marker:_______________________
☐ Negative
☐ Not done
Copy and complete questions 156-157 for additional molecular markers
CNS Leukemia
158. 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:
159. What was the disease status (based on hematological test results)?
☐ Primary induction failure - Go to question 163
☐ 1st complete remission (no previous marrow or
extramedullary relapse) (include CRi)
- Go to question 160
☐ 2nd complete remission - Go to question 160
☐ ≥ 3rd complete remission - Go to question 160
160. How many cycles of induction therapy were required to achieve
1st complete remission? (includes CRi) - Go to question 163
☐ 1 ☐ 2 ☐ ≥ 3
161. Was the recipient in remission by flow cytometry?
☐ Yes
☐ 1st relapse - Go to question 162
☐ 2nd relapse - Go to question 162
☐ ≥ 3rd relapse - Go to question 162
☐ No treatment - Go to question 163
☐ No ☐ Unknown
☐ Not applicable
- Go to question 163
162. Date of most recent relapse:__ __ __ __ / __ __ / __ __
YYYY
MM
DD
163. Date assessed: __ __ __ __ / __ __ / __ __ - Go to signature line
YYYY
MM
DD
Acute Leukemias of Ambiguous Lineage and Other Myeloid Neoplasms
164. 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)
165. Specify other acute leukemia of ambiguous lineage or myeloid neoplasm:
_____________________________________________________________________
CIBMTR Form 2402 revision 4 (page 23 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Status at transplantation:
166. 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
167. Date assessed: __ __ __ __ / __ __ / __ __ - Go to signature line
YYYY
MM
DD
Chronic Myelogenous Leukemia (CML)
168. Was therapy given prior to this HCT?
☐ Yes
☐ No
☐ Yes
☐ Yes
☐ Yes
☐ Yes
169. Combination chemotherapy
170.
Hydroxyurea (Droxia, Hydrea)
171. Tyrosine kinase inhibitor (e.g.imatinib mesylate, dasatinib, nilotinib)
172.
Interferon-α (Intron, Roferon) (includes PEG)
173. Other therapy
☐ No
☐ No
☐ No
☐ No
☐ Yes
174. Specify other therapy:_________________________________________________
☐ No
175. What was the disease status?
☐ Complete hematologic response (CHR) preceded only by
chronic phase
176. Specify level of response
☐ Complete hematologic response (CHR) preceded by
accelerated phase and/or blast phase
☐ Chronic phase
☐ Accelerated phase - Go to question 177
☐ Blast phase - Go to question 177
177. Number
☐ 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
178. Date assessed: __ __ __ __ / __ __ / __ __ - Go to signature line
YYYY
MM
DD
CIBMTR Form 2402 revision 4 (page 24 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
☐ 2nd
☐ 3rd or higher
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Myelodysplastic (MDS) / Myeloproliferative (MPN) Diseases
179. 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)
☐ Mastocytosis (1451)
☐ Myeloproliferative neoplasm (MPN), unclassifiable (60)
☐ Myeloid / lymphoid neoplasms with PDGFRA rearrangement (1461)
☐ Myeloid / lymphoid neoplasms with PDGFRB rearrangement (1462)
☐ Myeloid / lymphoid neoplasms with FGFR1 rearrangement (1463)
☐ Myeloid / lymphoid neoplasms with PCM1-JAK2 (1464)
☐ Chronic myelomonocytic leukemia (CMMoL) (54)
☐ Juvenile myelomonocytic leukemia (JMML / JCML) (no evidence of Ph or BCR / ABL) (36) - Go to question 202
☐ Atypical chronic myeloid leukemia (aCML), BCR-ABL1- (1440) - Go to question 202
☐ MDS / MPN with ring sideroblasts and thrombocytosis (MDS / MPN–RS–T) (1452)
☐ Myelodysplastic / myeloproliferative neoplasm, unclassifiable (69)
1
☐ Yes
180. Was the disease (MDS / MPN) therapy related?
☐ No
☐ Unknown
181. Did the recipient have a predisposing condition?
☐ Yes
☐ No
☐ Unknown
182. Specify condition
☐ Aplastic anemia
☐ Bloom syndrome
☐ Down syndrome
☐ Fanconi anemia
☐ Other condition
183. Specify other condition:________________________________
Laboratory Studies at Diagnosis of MDS:
184. WBC
☐ Known
☐ Unknown
185. ___ ___ ___ ___ ___ ___ ● ___ ☐ x 109/L (x 103/mm3)
☐ x 10 /L
6
CIBMTR Form 2402 revision 4 (page 25 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
186. Hemoglobin
☐ Known
☐ Unknown
187. ___ ___ ___ ___ ● ___ ___
☐ g/dL
☐ g/L
☐ mmol/L
188. Was RBC transfused ≤ 30 days before date of test?
☐ Yes
☐ No
☐ Yes
☐ No
189. Platelets
☐ Known 190. ___ ___ ___ ___ ___ ___ ___ ☐ x 10 /L (x 10 /mm ) ☐ x 10 /L
☐ Unknown
191. Were platelets transfused ≤ 7 days before date of test?
9
3
3
6
192. Neutrophils
☐ Known
☐ Unknown
193. ___ ___%
194. Blasts in bone marrow
☐ Known
☐ Unknown
195. ___ ___ ___ %
196. Were cytogenetics tested (karyotyping or FISH)?
☐ Yes
☐ No
☐ Unknown
197. Results of tests:
☐ Abnormalities identified
☐ No evaluable metaphases
☐ No abnormalities
Specify abnormalities identified at diagnosis:
198. International System for Human Cytogenetic Nomenclature (ISCN) compatible string:
___________________________________________________________________
199. Specify number of distinct cytogenetic abnormalities:
☐ One (1)
☐ Two (2)
☐ Three (3)
☐ Four or more (4 or more)
200. Specify abnormalities: (check all that apply)
Monosomy
☐ –5
☐ –7
☐ –13
☐ –20
☐ –Y
Trisomy
☐ +8
☐ +19
Translocation
☐ t(1;3)
☐ t(2;11)
CIBMTR Form 2402 revision 4 (page 26 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ t(3;3)
☐ t(3;21)
☐ t(6;9)
☐ t(11;16)
Deletion
☐ del(3q) / 3q-
☐ del(5q) / 5q-
☐ del(7q) / 7q-
☐ del(9q) / 9q-
☐ del(11q) / 11q-
☐ del(12p) / 12p-
☐ del(13q) / 13q-
☐ del(20q) / 20q-
Inversion
☐ inv(3)
Other
☐ i17q
☐ Other abnormality
201. Specify other abnormality:________________
202. Did the recipient progress or transform to a different MDS / MPN subtype between diagnosis and the start of the preparative regimen?
☐ Yes
☐ No
203. Specify the MDS / MPN subtype after transformation:
☐ Refractory cytopenia with unilineage dysplasia (RCUD) (includes refractory anemia (RA)) (51)
- Go to question 204
☐ Refractory anemia with ringed sideroblasts (RARS) (55) - Go to question 204
☐ Refractory anemia with excess blasts-1 (RAEB-1) (61) - Go to question 204
☐ Refractory anemia with excess blasts-2 (RAEB-2) (62) - Go to question 204
☐ Refractory cytopenia with multilineage dysplasia (RCMD) (64) - Go to question 204
☐ Childhood myelodysplastic syndrome (Refractory cytopenia of childhood (RCC)) (68)
- Go to question 204
☐ Myelodysplastic syndrome with isolated del(5q) (5q– syndrome) (66) - Go to question 204
☐ Myelodysplastic syndrome (MDS), unclassifiable (50) - Go to question 204
☐ Chronic neutrophilic leukemia (165) - Go to question 204
☐ Chronic eosinophilic leukemia, NOS (166) - Go to question 204
☐ Essential thrombocythemia (includes primary thrombocytosis, idiopathic thrombocytosis, hemorrhagic
thrombocythemia) (58) - Go to question 204
☐ Polycythemia vera (PCV) (57) - Go to question 204
☐ Mastocytosis (1451) - Go to question 204
☐ Myeloproliferative neoplasm (MPN), unclassifiable (60) - Go to question 204
☐ Myeloid / lymphoid neoplasms with PDGFRA rearrangement (1461) - Go to question 204
☐ Myeloid / lymphoid neoplasms with PDGFRB rearrangement (1462) - Go to question 204
☐ Primary myelofibrosis (includes chronic idiopathic myelofibrosis (CIMF), angiogenic myeloid metaplasia
(AMM), myelofibrosis / sclerosis with myeloid metaplasia (MMM), idiopathic myelofibrosis) (167)
- Go to question 204
CIBMTR Form 2402 revision 4 (page 27 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ Myeloid / lymphoid neoplasms with FGFR1 rearrangement (1463) - Go to question 204
☐ Myeloid / lymphoid neoplasms with PCM1-JAK2 (1464) - Go to question 204
☐ Chronic myelomonocytic leukemia (CMMoL) (54) - Go to question 204
☐ Atypical chronic myeloid leukemia (aCML), BCR-ABL1- (1440) - Go to question 233
☐ MDS / MPN with ring sideroblasts and thrombocytosis (MDS / MPN–RS–T) (1452) - Go to question 204
☐ Myelodysplastic / myeloproliferative neoplasm, unclassifiable (69) - Go to question 204
☐ Transformed to AML (70) - Go to question 205
204. Specify the date of the most recent transformation:
___ ___ ___ ___/ ___ ___ / ___ ___ - Go to question 206
YYYY
MM
DD
205. Date of MDS diagnosis:___ ___ ___ ___/ ___ ___ / ___ ___ - Go to signature line
YYYY
MM
DD
Laboratory studies at last evaluation prior to the start of the preparative regimen:
206. WBC
☐ Known
☐ Unknown
207. ___ ___ ___ ___ ___ ___ ● ___
☐ x 10 /L (x 10 /mm )
9
3
3
☐ x 10 /L
6
208. Hemoglobin
☐ Known
☐ Unknown
☐ mmol/L
210. Was RBC transfused ≤ 30 days before date of test? ☐ Yes
☐ No
209. ___ ___ ___ ___ ● ___ ___
☐ g/dL
☐ g/L
211. Platelets
☐ Known
☐ Unknown
212. ___ ___ ___ ___ ___ ___ ___ ☐ x 109/L (x 103/mm3)
☐ x 10 /L
6
213. Were platelets transfused ≤ 7 days before date of test?
214. Neutrophils
☐ Known
☐ Unknown
215. ___ ___%
216. Blasts in bone marrow
☐ Known
217. ___ ___ ___ %
☐ Unknown
CIBMTR Form 2402 revision 4 (page 28 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
☐ Yes
☐ No
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
218. Were cytogenetics tested (karyotyping or FISH)?
☐ Yes
☐ No
☐ Unknown
219. 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:
220. International System for Human Cytogenetic Nomenclature (ISCN) compatible string:
___________________________________________________________________
221. Specify number of distinct cytogenetic abnormalities:
☐ One (1) ☐ Two (2) ☐ Three (3) ☐ Four or more (4 or more)
222. Specify abnormalities: (check all that apply)
Monosomy
☐ –5
☐ –7
☐ –13
☐ –20
☐ –Y
Trisomy
☐ +8
☐ +19
Translocation
☐ t(1;3)
☐ t(2;11)
☐ t(3;3)
☐ t(3;21)
☐ t(6;9)
☐ t(11;16)
Deletion
☐ del(3q) / 3q-
☐ del(5q) / 5q-
☐ del(7q) / 7q-
☐ del(9q) / 9q-
☐ del(11q) / 11q-
☐ del(12p) / 12p-
☐ del(13q) / 13q-
☐ del(20q) / 20q-
Inversion
☐ inv(3)
Other
☐ i17q
☐ Other abnormality
223. Specify other abnormality:________________
CIBMTR Form 2402 revision 4 (page 29 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Status at Transplantation:
224. 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 228
☐ 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 225
☐ No response (NR)/stable disease (SD) – does not meet the criteria for at least HI, but no evidence of disease progression
- Go to question 228
☐ 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 226
☐ 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 227
☐ Not assessed - Go to signature line
225. 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 228
☐ 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 228
☐ HI-N – neutrophil count increase of ≥ 100% from pre-treatment level and an absolute increase of
≥ 500/mm3 - Go to question 228
226. Date of progression: ___ ___ ___ ___/ ___ ___ / ___ ___ - Go to question 228
YYYY
MM
DD
227. Date of relapse: ___ ___ ___ ___ / ___ ___ / ___ ___ - Go to question 228
YYYY
MM
DD
228. Date assessed: ___ ___ ___ ___ / ___ ___ / ___ ___ - Go to signature line
YYYY
MM
DD
CIBMTR Form 2402 revision 4 (page 30 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Other Leukemia (OL)
229. Specify the other leukemia classification:
☐ Chronic lymphocytic leukemia (CLL), NOS (34) - Go to question 231
☐ Chronic lymphocytic leukemia (CLL), B-cell / small lymphocytic lymphoma (SLL) (71) - Go to question 231
☐ Hairy cell leukemia (35) - Go to question 234
☐ Hairy cell leukemia variant (75) - Go to question 234
☐ Monoclonal B-cell lymphocytosis (76) - Go to signature line
☐ Prolymphocytic leukemia (PLL), NOS (37) - Go to question 231
☐ PLL, B-cell (73) - Go to question 231
☐ PLL, T-cell (74) - Go to question 231
☐ Other leukemia, NOS (30) - Go to question 233
☐ Other leukemia (39) - Go to question 230
230. Specify other leukemia:__________________________________________________ - Go to question 233
231. Was any 17p abnormality detected?
☐ Yes - If disease classification is CLL, go to question 232. If PLL, go to question 234.
☐ No
232. Did a histologic transformation to diffuse large B-cell lymphoma (Richter syndrome) occur at any time after
CLL diagnosis?
☐ Yes - Go to question 236 – Also complete NHL Disease Classification questions
☐ No - Go to question 234
Status at transplantation:
233. What was the disease status? (Atypical CML)
☐ Primary induction failure - Go to question 235
☐ 1st complete remission (no previous bone marrow or extramedullary relapse) - Go to question 235
☐ 2nd complete remission - Go to question 235
☐ ≥ 3rd complete remission - Go to question 235
☐ 1st relapse - Go to question 235
☐ 2nd relapse - Go to question 235
☐ ≥ 3rd relapse - Go to question 235
☐ No treatment - Go to signature line
234. What was the disease status? (CLL, PLL, Hairy cell leukemia)
☐ Complete remission (CR) - Go to question 235
☐ Partial remission (PR) - Go to question 235
☐ Stable disease (SD) - Go to question 235
☐ Progressive disease (Prog) - Go to question 235
☐ Untreated - Go to question 235
☐ Not assessed - Go to signature line
235. Date assessed: __ __ __ __ / __ __ / __ __ - Go to signature line
YYYY
MM DD
CIBMTR Form 2402 revision 4 (page 31 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Hodgkin and Non-Hodgkin Lymphoma
236. Specify the lymphoma histology: (at infusion)
Hodgkin Lymphoma Codes
☐ Hodgkin lymphoma, not otherwise specified (150)
☐ Lymphocyte depleted (154)
☐ Lymphocyte-rich (151)
☐ Mixed cellularity (153)
☐ Nodular lymphocyte predominant Hodgkin lymphoma (155)
☐ Nodular sclerosis (152)
Non-Hodgkin Lymphoma Codes
B-cell Neoplasms
☐ ALK+ large B-cell lymphoma (1833)
☐ B-cell lymphoma, unclassifiable, with features intermediate between DLBCL and classical Hodgkin lymphoma (149)
☐ Burkitt lymphoma (111)
☐ Burkitt-like lymphoma with 11q aberration (1834)
☐ Diffuse, large B-cell lymphoma- Activated B-cell type (non-GCB) (1821) - Go to question 238
☐ Diffuse, large B-cell lymphoma- Germinal center B-cell type (1820) - Go to question 238
☐ Diffuse large B-cell Lymphoma (cell of origin unknown) (107)
☐ DLBCL associated with chronic inflammation (1825)
☐ Duodenal-type follicular lymphoma (1815)
☐ EBV+ DLBCL, NOS (1823)
☐ EBV+ mucocutaneous ulcer (1824)
☐ Extranodal marginal zone B-cell lymphoma of mucosal associated lymphoid tissue type (MALT) (122)
☐ 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, predominantly large cell (Grade IIIA vs IIIB not specified) (1814)
☐ Follicular, predominantly small cleaved cell (Grade I follicle center lymphoma) (102)
☐ Follicular (grade unknown) (164)
☐ HHV8+ DLBCL, NOS (1826)
☐ High-grade B-cell lymphoma, with MYC and BCL2 and/or BCL6 rearrangements (1831)
☐ High-grade B-cell lymphoma, NOS (1830)
☐ Intravascular large B-cell lymphoma (136)
☐ Large B-cell lymphoma with IRF4 rearrangement (1832)
☐ Lymphomatoid granulomatosis (1835)
☐ Mantle cell lymphoma (115)
☐ Nodal marginal zone B-cell lymphoma (± monocytoid B-cells) (123)
☐ Pediatric nodal marginal zone lymphoma (1813)
☐ Pediatric-type follicular lymphoma (1816)
☐ Plasmablastic lymphoma (1836)
☐ Primary cutaneous DLBCL, leg type (1822)
☐ Primary cutaneous follicle center lymphoma (1817)
☐ Primary diffuse, large B-cell lymphoma of the CNS (118)
☐ Primary effusion lymphoma (138)
☐ Primary mediastinal (thymic) large B-cell lymphoma (125)
CIBMTR Form 2402 revision 4 (page 32 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ Splenic B-cell lymphoma/leukemia, unclassifiable (1811)
☐ Splenic diffuse red pulp small B-cell lymphoma (1812)
☐ Splenic marginal zone B-cell lymphoma (124)
☐ T-cell / histiocytic rich large B-cell lymphoma (120)
☐ Waldenstrom macroglobulinemia / Lymphoplasmacytic lymphoma (173)
☐ Other B-cell lymphoma (129) - Go to question 237
T-cell and NK-cell Neoplasms
☐ Adult T-cell lymphoma / leukemia (HTLV1 associated) (134)
☐ Aggressive NK-cell leukemia (27)
☐ Anaplastic large-cell lymphoma (ALCL), ALK positive (143)
☐ Anaplastic large-cell lymphoma (ALCL), ALK negative (144)
☐ Angioimmunoblastic T-cell lymphoma (131)
☐ Breast implant–associated anaplastic large-cell lymphoma (1861)
☐ Chronic lymphoproliferative disorder of NK cells (1856)
☐ Enteropathy-type T-cell lymphoma (133)
☐ Extranodal NK / T-cell lymphoma, nasal type (137)
☐ Follicular T-cell lymphoma (1859)
☐ Hepatosplenic T-cell lymphoma (145)
☐ Indolent T-cell lymphoproliferative disorder of the GI tract (1858)
☐ Monomorphic epitheliotropic intestinal T-cell lymphoma (1857)
☐ Mycosis fungoides (141)
☐ Nodal peripheral T-cell lymphoma with TFH phenotype (1860)
☐ Peripheral T-cell lymphoma (PTCL), NOS (130)
☐ Primary cutaneous acral CD8+ T-cell lymphoma (1853)
☐ Primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder (1854)
☐ Primary cutaneous CD8+ aggressive epidermotropic cytotoxic T-cell lymphoma (1852)
☐ Primary cutaneous CD30+ T-cell lymphoproliferative disorders [Primary cutaneous anaplastic large-cell lymphoma (C-ALCL), lymphoid
papulosis] (147)
☐ Primary cutaneous γδ T-cell lymphoma (1851)
☐ Sezary syndrome (142)
☐ Subcutaneous panniculitis-like T-cell lymphoma (146)
☐ Systemic EBV+ T-cell lymphoma of childhood (1855)
☐ T-cell large granular lymphocytic leukemia (126)
☐ Other T-cell / NK-cell lymphoma (139) - Go to question 237
Posttransplant lymphoproliferative disorders (PTLD)
☐ Classical Hodgkin lymphoma PTLD (1876)
☐ Florid follicular hyperplasia PTLD (1873)
☐ Infectious mononucleosis PTLD (1872)
☐ Monomorphic PTLD (B- and T-/NK-cell types) (1875)
☐ Plasmacytic hyperplasia PTLD (1871)
☐ Polymorphic PTLD (1874)
237. Specify other lymphoma histology: ______________________ - Go to question 239
238. Assignment of DLBCL (germinal center B-cell type vs. activated B-cell type) subtype was based on:
☐ Immunohistochemistry (e.g. Han’s algorithm)
☐ Gene expression profile
CIBMTR Form 2402 revision 4 (page 33 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
☐ Unknown method
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
239. Is the lymphoma histology reported at transplant a transformation from CLL?
☐ Yes
☐ No
240. Was any 17p abnormality detected?
☐ Yes
☐ No
241. Is the lymphoma histology reported at transplant a transformation from a different lymphoma histology? (Not CLL)
☐ Yes
☐ No
242. Specify the original lymphoma histology: (prior to transformation)
Hodgkin Lymphoma Codes
☐ Hodgkin lymphoma, not otherwise specified (150)
☐ Lymphocyte depleted (154)
☐ Lymphocyte-rich (151)
☐ Mixed cellularity (153)
☐ Nodular lymphocyte predominant Hodgkin lymphoma (155)
☐ Nodular sclerosis (152)
Non-Hodgkin Lymphoma Codes
B-cell Neoplasms
☐ ALK+ large B-cell lymphoma (1833)
☐ Burkitt lymphoma (111)
☐ Burkitt-like lymphoma with 11q aberration (1834)
☐ Diffuse, large B-cell lymphoma- Activated B-cell type (non-GCB) (1821) - Go to question 238
☐ Diffuse, large B-cell lymphoma- Germinal center B-cell type (1820) - Go to question 238
☐ Diffuse large B-cell Lymphoma (cell of origin unknown) (107)
☐ DLBCL associated with chronic inflammation (1825)
☐ Duodenal-type follicular lymphoma (1815)
☐ EBV+ DLBCL, NOS (1823)
☐ EBV+ mucocutaneous ulcer (1824)
☐ Extranodal marginal zone B-cell lymphoma of mucosal associated lymphoid tissue type (MALT) (122)
☐ 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, predominantly large cell (Grade IIIA vs IIIB not specified) (1814)
☐ Follicular, predominantly small cleaved cell (Grade I follicle center lymphoma) (102)
☐ Follicular (grade unknown) (164)
☐ HHV8+ DLBCL, NOS (1826)
☐ High-grade B-cell lymphoma, with MYC and BCL2 and/or BCL6 rearrangements (1831)
☐ High-grade B-cell lymphoma, NOS (1830)
☐ Intravascular large B-cell lymphoma (136)
☐ Large B-cell lymphoma with IRF4 rearrangement (1832)
☐ Lymphomatoid granulomatosis (1835)
☐ Mantle cell lymphoma (115)
☐ Nodal marginal zone B-cell lymphoma (± monocytoid B-cells) (123)
☐ Pediatric nodal marginal zone lymphoma (1813)
☐ Pediatric-type follicular lymphoma (1816)
☐ B-cell lymphoma, unclassifiable, with features intermediate between DLBCL and classical Hodgkin
lymphoma (149)
CIBMTR Form 2402 revision 4 (page 34 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ Plasmablastic lymphoma (1836)
☐ Primary cutaneous DLBCL, leg type (1822)
☐ Primary cutaneous follicle center lymphoma (1817)
☐ Primary diffuse, large B-cell lymphoma of the CNS (118)
☐ Primary effusion lymphoma (138)
☐ Primary mediastinal (thymic) large B-cell lymphoma (125)
☐ Splenic B-cell lymphoma/leukemia, unclassifiable (1811)
☐ Splenic diffuse red pulp small B-cell lymphoma (1812)
☐ Splenic marginal zone B-cell lymphoma (124)
☐ T-cell / histiocytic rich large B-cell lymphoma (120)
☐ Waldenstrom macroglobulinemia / Lymphoplasmacytic lymphoma (173)
☐ Other B-cell lymphoma (129) - Go to question 243
T-cell and NK-cell Neoplasms
☐ Adult T-cell lymphoma / leukemia (HTLV1 associated) (134)
☐ Aggressive NK-cell leukemia (27)
☐ Anaplastic large-cell lymphoma (ALCL), ALK positive (143)
☐ Anaplastic large-cell lymphoma (ALCL), ALK negative (144)
☐ Angioimmunoblastic T-cell lymphoma (131)
☐ Breast implant–associated anaplastic large-cell lymphoma (1861)
☐ Chronic lymphoproliferative disorder of NK cells (1856)
☐ Enteropathy-type T-cell lymphoma (133)
☐ Extranodal NK / T-cell lymphoma, nasal type (137)
☐ Follicular T-cell lymphoma (1859)
☐ Hepatosplenic T-cell lymphoma (145)
☐ Indolent T-cell lymphoproliferative disorder of the GI tract (1858)
☐ Monomorphic epitheliotropic intestinal T-cell lymphoma (1857)
☐ Mycosis fungoides (141)
☐ Nodal peripheral T-cell lymphoma with TFH phenotype (1860)
☐ Peripheral T-cell lymphoma (PTCL), NOS (130)
☐ Primary cutaneous acral CD8+ T-cell lymphoma (1853)
☐ Primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder (1854)
☐ Primary cutaneous CD8+ aggressive epidermotropic cytotoxic T-cell lymphoma (1852)
☐ Primary cutaneous CD30+ T-cell lymphoproliferative disorders [Primary cutaneous anaplastic large-cell
lymphoma (C-ALCL), lymphoid papulosis] (147)
☐ Primary cutaneous γδ T-cell lymphoma (1851)
☐ Sezary syndrome (142)
☐ Subcutaneous panniculitis-like T-cell lymphoma (146)
☐ Systemic EBV+ T-cell lymphoma of childhood (1855)
☐ T-cell large granular lymphocytic leukemia (126)
☐ Other T-cell / NK-cell lymphoma (139) - Go to question 243
Posttransplant lymphoproliferative disorders (PTLD)
☐ Classical Hodgkin lymphoma PTLD (1876)
☐ Florid follicular hyperplasia PTLD (1873)
CIBMTR Form 2402 revision 4 (page 35 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ Infectious mononucleosis PTLD (1872)
☐ Monomorphic PTLD (B- and T-/NK-cell types) (1875)
☐ Plasmacytic hyperplasia PTLD (1871)
☐ Polymorphic PTLD (1874)
243. Specify other lymphoma histology:_______________________
244. Date of original lymphoma diagnosis: __ __ __ __ / __ __ / __ __
YYYY
MM DD
(report the date of diagnosis of original lymphoma subtype)
245. Was a PET (or PET/CT) scan performed? (at last evaluation prior to the start of the preparative regimen / infusion)
☐ Yes
☐ No
246. Was the PET (or PET/CT) scan positive for lymphoma involvement at any disease
site?
☐ Yes
☐ No
247. Date of PET scan
☐ Known
☐ Unknown
248. Date of PET (or PET/CT) scan : __ __ __ __ / __ __ / __ __
YYYY
MM
DD
249. Deauville (five-point) score of the PET (or PET/CT) scan
☐ Known
☐ Unknown
250. Scale
☐ 1- no uptake or no residual uptake
☐ 2- slight uptake, but below blood pool (mediastinum)
☐ 3- uptake above mediastinal, but below or equal to uptake
in the liver
☐ 4- uptake slightly to moderately higher than liver
☐ 5- markedly increased uptake or any new lesion
Status at transplantation / infusion:
251. What was the disease status?
☐ Disease untreated - Go to signature line
☐ PIF res - Primary induction failure – resistant: NEVER in COMPLETE remission but with stable or progressive disease on treatment.
- Go to question 252
☐ PIF sen / PR1 - Primary induction failure – sensitive: NEVER in COMPLETE remission but with partial remission on treatment.
- Go to question 252
☐ PIF unk - Primary induction failure – sensitivity unknown - Go to question 252
☐ CR1 - 1st complete remission: no bone marrow or extramedullary relapse prior to transplant - Go to question 252
☐ CR2 - 2nd complete remission - Go to question 252
☐ CR3+ - 3rd or subsequent complete remission - Go to question 252
☐ REL1 unt - 1st relapse – untreated; includes either bone marrow or extramedullary relapse - Go to question 252
☐ REL1 res - 1st relapse – resistant: stable or progressive disease with treatment - Go to question 252
☐ REL1 sen - 1st relapse – sensitive: partial remission (if complete remission was achieved, classify as CR2) - Go to question 252
☐ REL1 unk - 1st relapse – sensitivity unknown - Go to question 252
☐ REL2 unt - 2nd relapse – untreated: includes either bone marrow or extramedullary relapse - Go to question 252
CIBMTR Form 2402 revision 4 (page 36 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
☐ REL2 res - 2nd relapse – resistant: stable or progressive disease with treatment - Go to question 252
☐ REL2 sen - 2nd relapse – sensitive: partial remission (if complete remission achieved, classify as CR3+) - Go to question 252
☐ REL2 unk - 2nd relapse – sensitivity unknown - Go to question 252
☐ REL3+ unt - 3rd or subsequent relapse – untreated; includes either bone marrow or extramedullary relapse - Go to question 252
☐ REL3+ res - 3rd or subsequent relapse – resistant: stable or progressive disease with treatment - Go to question 252
☐ REL3+ sen - 3rd or subsequent relapse – sensitive: partial remission (if complete remission achieved, classify as CR3+)
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
- Go to question 252
☐ REL3+ unk - 3rd relapse or greater – sensitivity unknown - Go to question 252
252. Total number of lines of therapy received: (between diagnosis and HCT / infusion)
☐ 1 line ☐ 2 lines ☐ 3+ lines
253. Date assessed : __ __ __ __ / __ __ / __ __ - Go to signature line
YYYY
MM
DD
CIBMTR Form 2402 revision 4 (page 37 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 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)
254. Specify the multiple myeloma / plasma cell disorder (PCD) classification:
☐ Multiple myeloma (178) - Go to questions 256
☐ Multiple myeloma-light chain only (186) - Go to questions 256
☐ Multiple myeloma-non-secretory (187) - Go to questions 262
☐ Plasma cell leukemia (172) - Go to questions 264
☐ Solitary plasmacytoma (no evidence of myeloma) (175) - Go to questions 261
☐ Smoldering myeloma (180) - Go to questions 264
☐ Amyloidosis (174) - Go to questions 257
☐ Osteosclerotic myeloma (176) - Go to question 264
☐ Monoclonal gammopathy of renal significance (MGRS) (1611) - Go to question 258
☐ Other plasma cell disorder (179) - Go to question 255
255. Specify other plasma cell disorder:_________________________________________ - Go to question 264
256. Specify heavy and/or light chain type: (check all that apply)
☐ IgG kappa
☐ IgA kappa
☐ IgM kappa
☐ IgD kappa
☐ IgE kappa
☐ IgG lambda
☐ IgA lambda
☐ IgM lambda
☐ IgD lambda
☐ IgE lambda
☐ IgG (heavy chain only)
☐ IgA (heavy chain only)
☐ IgM (heavy chain only)
☐ IgD (heavy chain only)
☐ IgE (heavy chain only)
☐ Kappa (light chain only)
☐ Lambda (light chain only)
- Go to question 262
257. Specify Amyloidosis classification
☐ AL amyloidosis
- Go to question 264
☐ AH amyloidosis
☐ AHL amyloidosis
258. Select monoclonal gammopathy of renal significance (MGRS) classification:
☐ Light chain fanconi syndrome - Go to question 260
☐ Proximal tubulopathy without crystals - Go to question 260
☐ Crystal-storing histiocytosis - Go to question 260
☐ Non-amyloid fibrillary glomerulonephritis - Go to question 260
☐ Immunotactoid glomerulopathy (ITGN)/ Glomerulonephritis with organized monoclonal microtubular
immunoglobulin deposits (GOMMID) - Go to question 260
☐ Type 1 cryoglobulinemic glomerulonephritis - Go to question 260
☐ Monoclonal immunoglobulin deposition disease (MIDD) - Go to question 259
CIBMTR Form 2402 revision 4 (page 38 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ Proliferative glomerulonephritis with monoclonal immunoglobulin G deposits (PGNMID)
- Go to question 260
☐ C3 glomerulopathy with monoclonal gammopathy - Go to question 260
☐ Unknown - Go to question 260
259. Select monoclonal immunoglobulin deposition disease (MIDD) subtype:
☐ Light chain deposition disease (LCDD)
☐ Light and heavy chain deposition disease (LHCDD)
☐ Heavy chain deposition disease (HCDD)
260. Was documentation submitted to the CIBMTR? (e.g. pathology report)
☐ Yes - Go to question 264
261. Solitary plasmacytoma was:
☐ Extramedullary - Go to question 264
☐ No - Go to question 264
☐ Bone derived - Go to question 264
262. 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 question 263
☐ Stage II (Fitting neither Stage I or Stage III) - Go to question 263
☐ 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 question 263
☐ Unknown - Go to question 264
263. 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)
264. Did the recipient have a preceding or concurrent plasma cell disorder?
☐ Yes
☐ No
265. Specify preceding / concurrent disorder:
☐ Multiple myeloma
☐ Multiple myeloma-light chain only
☐ Multiple myeloma-non-secretory
☐ Plasma cell leukemia
☐ Solitary plasmacytoma (no evidence of myeloma)
☐ Smoldering myeloma
☐ Amyloidosis
☐ Osteosclerotic myeloma / POEMS syndrome
☐ Monoclonal gammopathy of unknown significance (MGUS)
☐ Monoclonal gammopathy of renal significance (MGRS)
☐ Other plasma cell disorder (PCD)
266. Specify other preceding/concurrent disorder: _______________________________
267. Date of diagnosis of preceding / concurrent disorder: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
Copy questions 264- 267 to report more than one concurrent or preceding disorder.
CIBMTR Form 2402 revision 4 (page 39 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
268. Serum β2-microglobulin:
☐ Known
☐ Unknown
269. Serum β2-microglobulin: ___ ___ ___ ● ___ ___ ___
☐ μg/dL
☐ mg/L
☐ nmol/L
270. Serum albumin:
☐ Known
☐ Unknown
271. Serum albumin: ___ ___ ● ___
☐ g/dL
☐ g/L
I.S.S. at diagnosis:
272. Stage
☐ Known
☐ Unknown
273. Stage
☐ 1 (β2-mic < 3.5, S. albumin ≥ 3.5)
☐ 2 (not fitting stage 1 or 3)
☐ 3 (β2-mic ≥ 5.5; S. albumin —)
R - I.S.S. at diagnosis:
274. Stage
☐ Known
☐ Unknown
275. Stage
☐ 1 (ISS stage I and standard-risk chromosomal abnormalities by iFISH and normal LDH)
☐ 2 (Not R-ISS stage I or III)
☐ 3 (ISS stage III and either high-risk chromosomal abnormalities by iFISH or high LDH)
276. Plasma cells in blood by flow cytometry
☐ Known
☐ Unknown
277. ___ ___%
278. ___ ___ ___ ___ ___ • ___ ___ ☐ x 109/L (x 103/mm3)
☐ x 10 /L
6
279. Plasma cells in blood by morphologic assessment
☐ Known
☐ Unknown
280. ___ ___%
281. ___ ___ ___ ___ ___ ● ___ ___ ☐ x 109/L (x 103/mm3)
☐ x 10 /L
6
282. LDH
☐ Known
☐ Unknown
283. ___ ___ ___ ___ ___ ● ___ ___
☐ U/L
☐ μkat/L
284. Upper limit of normal for LDH: ___ ___ ___ ___ ___ ● ___ ___
CIBMTR Form 2402 revision 4 (page 40 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
285. Were cytogenetics tested (karyotyping or FISH)?
☐ Yes
☐ No
☐ Unknown
286. Were cytogenetics tested via FISH?
☐ Yes
☐ No
287. Results of tests:
☐ Abnormalities identified
☐ No abnormalities
Specify cytogenetic abnormalities
identified via FISH at diagnosis:
288. International System for Human
Cytogenetic Nomenclature (ISCN)
compatible string:__________________
289. Specify abnormalities
(check all that apply)
Trisomy
☐ +3
☐ +5
☐ +7
☐ +9
☐ +11
☐ +15
☐ +19
Translocation
☐ t(4;14)
☐ t(6;14)
☐ t(11;14)
☐ t(14;16)
☐ t(14;20)
Deletion
☐ del (13)/13q☐ del (17)/17p-
Monosomy
☐ - 13
☐ - 17
Other
☐ Hyperdiploid (>50)
☐ Hypodiploid (<46)
☐ MYC rearrangement
☐ Any abnormality at 1q
☐ Any abnormality at 1p
☐ Other abnormality
290. Specify other abnormality:
_____________________
CIBMTR Form 2402 revision 4 (page 41 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
291. Was documentation submitted to the CIBMTR? (e.g. FISH report) ☐ Yes
☐ No
292. Were cytogenetics tested via karyotyping?
☐ Yes
☐ No
293. Results of tests:
☐ Abnormalities identified
☐ No evaluable metaphases
☐ No abnormalities
Specify cytogenetic abnormalities
identified via conventional cytogenetics at
diagnosis:
294. International System for Human
Cytogenetic Nomenclature (ISCN)
compatible string:__________________
295. Specify abnormalities
(check all that apply)
Trisomy
☐ +3
☐ +5
☐ +7
☐ +9
☐ +11
☐ +15
☐ +19
Translocation
☐ t(4;14)
☐ t(6;14)
☐ t(11;14)
☐ t(14;16)
☐ t(14;20)
Deletion
☐ del (13)/13q☐ del (17)/17p-
Monosomy
☐ - 13
☐ - 17
Other
☐ Hyperdiploid (>50)
☐ Hypodiploid (<46)
☐ MYC rearrangement
☐ Any abnormality at 1q
☐ Any abnormality at 1p
☐ Other abnormality
296. Specify other abnormality:
_____________________
CIBMTR Form 2402 revision 4 (page 42 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
297. Was documentation submitted to the CIBMTR? (e.g. karyotyping report)
☐ Yes
☐ No
298. What was the disease status?
☐ Stringent complete remission (sCR)
☐ Complete remission (CR)
☐ Very good partial remission (VGPR )
☐ Partial remission (PR)
☐ Stable disease (SD)
☐ Progressive disease (PD)
☐ Relapse from CR (Rel) (untreated)
☐ Unknown
299. Date assessed: __ __ __ __ / __ __ / __ __ - Go to signature line
YYYY
MM
DD
300. Specify amyloidosis hematologic response? (for Amyloid patients only)
☐ Complete remission
☐ Very good partial response
☐ Partial response
☐ Stable disease
☐ Progression
☐ Relapse from CR
☐ Untreated
301. Date assessed: __ __ __ __ / __ __ / __ __ - Go to signature line
YYYY
MM
DD
CIBMTR Form 2402 revision 4 (page 43 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Solid Tumors
302. Specify the solid tumor classification:
☐ Bone sarcoma (excluding Ewing family tumors) (273)
☐ Breast cancer (250)
☐ Central nervous system tumor, including CNS PNET (220)
☐ Cervical (212)
☐ Colorectal (228)
☐ Ewing family tumors of bone (including PNET) (275)
☐ Ewing family tumors, extraosseous (including PNET) (276)
☐ External genitalia (211)
☐ Fibrosarcoma (244)
☐ Gastric (229)
☐ Germ cell tumor, extragonadal (225)
☐ Head / neck (201)
☐ Hemangiosarcoma (246)
☐ Hepatobiliary (207)
☐ Leiomyosarcoma (242)
☐ Liposarcoma (243)
☐ Lung, non-small cell (203)
☐ Lung, not otherwise specified (230)
☐ Lung, small cell (202)
☐ Lymphangio sarcoma (247)
☐ Mediastinal neoplasm (204)
☐ Medulloblastoma (226)
☐ Melanoma (219)
☐ Neuroblastoma (222)
☐ Neurogenic sarcoma (248)
☐ Ovarian (epithelial) (214)
☐ Pancreatic (206)
☐ Prostate (209)
☐ Renal cell (208)
☐ Retinoblastoma (223)
☐ Rhabdomyosarcoma (232)
☐ Soft tissue sarcoma (excluding Ewing family tumors) (274)
☐ Synovial sarcoma (245)
☐ Testicular (210)
☐ Thymoma (231)
☐ Uterine (213)
☐ Vaginal (215)
☐ Wilm tumor (221)
☐ Solid tumor, not otherwise specified (200)
☐ Other solid tumor (269)
303. Specify other solid tumor:________________________________
- Go to signature line
CIBMTR Form 2402 revision 4 (page 44 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Severe Aplastic Anemia
304. 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)
305. Specify other acquired cytopenic syndrome:__________________
- Go to signature line
CIBMTR Form 2402 revision 4 (page 45 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Inherited Abnormalities of Erythrocyte Differentiation or Function
306. Specify the inherited abnormalities of erythrocyte differentiation or function classification:
☐ Paroxysmal nocturnal hemoglobinuria (PNH) (56) - Go to signature line
☐ Shwachman-Diamond (305) - Go to question 309
☐ Diamond-Blackfan anemia (pure red cell aplasia) (312) - Go to question 309
☐ Other constitutional anemia (319) - Go to question 307
☐ Fanconi anemia (311) (If the recipient developed MDS or AML, indicate MDS or AML as the primary disease) - Go to question 309
☐ Sickle thalassemia (355) - Go to question 309
☐ Sickle cell disease (356) - Go to question 309
☐ Beta thalassemia major (357) - Go to question 309
☐ Other hemoglobinopathy (359)
307. Specify other constitutional anemia:_________________________________________ - Go to question 309
308. Specify other hemoglobinopathy:___________________________________________ - Go to question 309
309. Did the recipient receive gene therapy to treat the inherited abnormalities of erythrocyte differentiation or
function?
☐ Yes – Also complete Cellular Therapy Product and Infusion forms 4003 and 4006. If sickle cell or
sickle thalassemia, go to question 310. If beta thalassemia, go to question 313, else go to signature
line
☐ No - If sickle cell or sickle thalassemia, go to question 310. If beta thalassemia, go to question 313, _
else go to signature line
310. Was tricuspid regurgitant jet velocity (TRJV) measured by Echocardiography pre-HCT? (sickle cell, sickle
thalassemia and beta thalassemia major only)
☐ Yes
☐ No
☐ Unknown
311. TRJV measurement:
☐ Known
☐ Unknown
312. TRJV measurement: __ __ m/sec
313. Was liver iron content (LIC) tested within 6 months prior to infusion? (sickle cell, sickle thalassemia, beta
thalassemia major only)
☐ Yes
☐ No
314. Liver iron content ___ ___ ___ mg iron / g liver dry weight
315. Method used to estimate LIC?
☐ T2*MRI
☐ SQUID MRI
☐ FerriScan
CIBMTR Form 2402 revision 4 (page 46 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
☐ Liver biopsy ☐ Other
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Beta thalassemia major
316. Is the patient red blood cell dependent? (requiring transfusion to maintain HGB >7g/dL)
☐ Yes
☐ No
317. Year of first transfusion (since diagnosis): ___ ___ ___ ___
YYYY
318. Was iron chelation therapy given at any time since diagnosis?
☐ Yes
☐ No
☐ Unkown
319. Did iron chelation therapy meet the following criteria:
initiated within 18 months of the first transfusion and
administered for at least 5 days / week (either oral or
parenteral iron chelation medication)?
☐ Yes, iron chelation therapy given as specified above
- Go to question 322
☐ No, iron chelation therapy given, but not meeting criteria
listed - Go to question 320
☐ Iron chelation therapy given, but details of administration
unknown - Go to question 322
320. Specify reason criteria not met:
☐ Non-adherance - Go to question 322
☐ Toxicity due to iron chelation therapy
- Go to question 322
☐ Other, specify
321. Specify other reason criteria not
met:
_________________________
322. Year iron chelation therapy started:
☐ Known
☐ Unknown
323. Year started: ___ ___ ___ ___
_ YYYY
324. Did the recipient have hepatomegaly? (> 2 cm below costal margin)
☐ Yes
☐ No
☐ Unknown
325. Liver size as measured below the costal margin at most recent evaluation prior to
infusion: ___ ___ cm
326. Was a liver biopsy performed at any time since diagnosis?
☐ Yes
☐ No
327. Date assessed:
☐ Known
☐ Unknown
☐ Absent ☐ Unknown
☐ Absent ☐ Unknown
Chronic hepatitis
☐ Absent ☐ Unknown
Was documentation submitted to the CIBMTR? (e.g., liver biopsy) ☐ Yes
☐ No
329. Liver cirrhosis
330. Bridging fibrosis
331.
332.
328. Date assessed: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
☐ Present
☐ Present
☐ Present
CIBMTR Form 2402 revision 4 (page 47 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
333. Is there evidence of abnormal cardiac iron deposition based on MRI of the heart at time of infusion?
☐ Yes
☐ No
334. Did patient have a splenectomy at any time prior to infusion?
☐ Yes
☐ No
☐ Unknown
☐ Yes
☐ No
☐ Unknown
Laboratory studies at last evaluation prior to start of preparative regimen
335. Serum Iron
☐ Known
☐ Unknown
336. ___ ___ ___ ☐ µg / dL
☐ µmol / L
337. Total iron binding capacity (TIBC)
☐ Known
☐ Unknown
338. ___ ___ ___ ☐ µg / dL
☐ µmol / L
339. Was serum bilirubin less than two times the upper limit of normal?
CIBMTR Form 2402 revision 4 (page 48 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Disorders of the Immune System
340. Specify disorder of immune system classification
☐ Adenosine deaminase (ADA) deficiency / severe combined immunodeficiency (SCID) (401) - Go to question 343
☐ Absence of T and B cells SCID (402) - Go to question 343
☐ Absence of T, normal B cell SCID (403) - Go to question 343
☐ Omenn syndrome (404) - Go to question 343
☐ Reticular dysgenesis (405) - Go to question 343
☐ Bare lymphocyte syndrome (406) - Go to question 343
☐ Other SCID (419) - Go to question 341
☐ SCID, not otherwise specified (410) - Go to question 343
☐ Ataxia telangiectasia (451) - Go to question 343
☐ HIV infection (452) - Go to question 343
☐ DiGeorge anomaly (454) - Go to question 343
☐ Common variable immunodeficiency (457) - Go to question 343
☐ Leukocyte adhesion deficiencies, including GP180, CD-18, LFA and WBC adhesion deficiencies (459) - Go to question 343
☐ Kostmann agranulocytosis (congenital neutropenia) (460) - Go to question 343
☐ Neutrophil actin deficiency (461) - Go to question 343
☐ Cartilage-hair hypoplasia (462) - Go to question 343
☐ CD40 ligand deficiency (464) - Go to question 343
☐ Other immunodeficiencies (479) - Go to question 342
☐ Immune deficiency, not otherwise specified (400) - Go to question 343
☐ Chediak-Higashi syndrome (456) – Also complete Pigmentary Dilution Disorder (PDD) Pre-HCT Data Form - Go to question 343
☐ Griscelli syndrome type 2 (465) – Also complete Pigmentary Dilution Disorder (PDD) Pre-HCT Data Form - Go to question 343
☐ Hermansky-Pudlak syndrome type 2 (466) – Also complete Pigmentary Dilution Disorder (PDD) Pre-HCT Data Form
- Go to question 343
☐ Other pigmentary dilution disorder (469) – Also complete Pigmentary Dilution Disorder (PDD) Pre-HCT Data Form
- Go to question 343
☐ Chronic granulomatous disease (455) - Go to question 343
☐ Wiskott-Aldrich syndrome (453) - Go to question 343
☐ X-linked lymphoproliferative syndrome (458) - Go to question 343
341. Specify other SCID:_____________________________________________________ - Go to question 344
342. Specify other immunodeficiency:___________________________________________ - Go to question 344
343. Specify other pigmentary dilution disorder:___________________________________ - Go to question 344
344. Did the recipient have an active or recent infection with a viral pathogen within 60 days of HCT?
☐ Yes
☐ No
345. Specify viral pathogen (check all that apply)
☐ 304 Adenovirus
☐ 341 BK Virus
☐ 344 Coronavirus
☐ 303 Cytomegalovirus (CMV)
☐ 347 Chikaugunya Virus
☐ 346 Dengue Virus
☐ 325 Enterovirus (ECHO, Coxsackie)
☐ 327 Enterovirus D68 (EV-D68)
CIBMTR Form 2402 revision 4 (page 49 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ 326 Enterovirus (polio)
☐ 328 Enterovirus NOS
☐ 318 Epstein-Barr Virus (EBV)
☐ 306 Hepatitis A Virus
☐ 307 Hepatitis B Virus
☐ 308 Hepatitis C Virus
☐ 340 Hepatitis E
☐ 301 Herpes Simplex Virus (HSV)
☐ 317 Human herpesvirus 6 (HHV-6)
☐ 309 Human Immunodeficiency Virus 1 or 2
☐ 343 Human metapneumovirus
☐ 322 Human Papillomavirus (HPV)
☐ 349 Human T-lymphotropic Virus 1 or 2
☐ 310 Influenza, NOS
☐ 323 Influenza A Virus
☐ 324 Influenza B Virus
☐ 342 JC Virus (Progressive Multifocal Leukoencephalopathy (PML))
☐ 311 Measles Virus (Rubeola)
☐ 312 Mumps Virus
☐ 345 Norovirus
☐ 316 Human Parainfluenza Virus (all species)
☐ 314 Respiratory Syncytial Virus (RSV)
☐ 321 Rhinovirus (all species)
☐ 320 Rotavirus (all species)
☐ 315 Rubella Virus
☐ 302 Varicella Virus
☐ 348 West Nile Virus (WNV)
346. Has the recipient ever been infected with PCP/PJB?
347. Does the recipient have GVHD due to maternal cell engraftment pre-HCT? (SCID only)
CIBMTR Form 2402 revision 4 (page 50 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
☐ Yes
☐ Yes
☐ No
☐ No
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Inherited Abnormalities of Platelets
348. Specify inherited abnormalities of platelets classification
☐ Congenital amegakaryocytosis / congenital thrombocytopenia (501)
☐ Glanzmann thrombasthenia (502)
☐ Other inherited platelet abnormality (509)
349. Specify other inherited platelet abnormality:__________________
- Go to signature line
CIBMTR Form 2402 revision 4 (page 51 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Inherited Disorders of Metabolism
350. 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
352. Loes composite score: __ __ Adrenoleukodystrophy (ALD) only
- Go to signature line
☐ Aspartyl glucosaminidase (561)
☐ Fucosidosis (562)
☐ Mannosidosis (563)
☐ Polysaccharide hydrolase abnormality, not otherwise specified (560)
☐ Other inherited metabolic disorder (529)
351.
☐ Inherited metabolic disorder, not otherwise specified (520)
Specify other inherited metabolic disorder:__________________
- Go to signature line
CIBMTR Form 2402 revision 4 (page 52 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Histiocytic disorders
353. Specify histiocytic disorder classification
☐ Hemophagocytic lymphohistiocytosis (HLH) (571) - Go to question 355
☐ Langerhans cell histiocytosis (histiocytosis-X) (572)
☐ Hemophagocytosis (reactive or viral associated) (573)
☐ Malignant histiocytosis (574)
☐ Other histiocytic disorder (579) - Go to question 354
☐ Histiocytic disorder, not otherwise specified (570)
354. Specify other histiocytic disorder:__________________________________________ - Go to signature line
355. Did the recipient have an active or recent infection with a viral pathogen within 60 days of HCT?
Hemophagocytic lymphohistiocytosis (HLH) only
☐ Yes
☐ No
356. Specify viral pathogen (check all that apply)
☐ 304 Adenovirus
☐ 341 BK Virus
☐ 344 Coronavirus
☐ 303 Cytomegalovirus (CMV)
☐ 347 Chikaugunya Virus
☐ 346 Dengue Virus
☐ 325 Enterovirus (ECHO, Coxsackie)
☐ 327 Enterovirus D68 (EV-D68)
☐ 326 Enterovirus (polio)
☐ 328 Enterovirus NOS
☐ 318 Epstein-Barr Virus (EBV)
☐ 306 Hepatitis A Virus
☐ 307 Hepatitis B Virus
☐ 308 Hepatitis C Virus
☐ 340 Hepatitis E
☐ 301 Herpes Simplex Virus (HSV)
☐ 317 Human herpesvirus 6 (HHV-6)
☐ 309 Human Immunodeficiency Virus 1 or 2
☐ 343 Human metapneumovirus
☐ 322 Human Papillomavirus (HPV)
☐ 349 Human T-lymphotropic Virus 1 or 2
☐ 310 Influenza, NOS
☐ 323 Influenza A Virus
☐ 324 Influenza B Virus
☐ 342 JC Virus (Progressive Multifocal Leukoencephalopathy (PML))
☐ 311 Measles Virus (Rubeola)
☐ 312 Mumps Virus
☐ 345 Norovirus
☐ 316 Human Parainfluenza Virus (all species)
☐ 314 Respiratory Syncytial Virus (RSV)
☐ 321 Rhinovirus (all species)
CIBMTR Form 2402 revision 4 (page 53 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ 320 Rotavirus (all species)
☐ 315 Rubella Virus
☐ 302 Varicella Virus
☐ 348 West Nile Virus (WNV)
357. Has the recipient ever been infected with PCP/PJB?
- Go to signature line
CIBMTR Form 2402 revision 4 (page 54 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
☐ Yes
☐ No
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Autoimmune Diseases
358. 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)
☐ 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) - Go to question 359
Bowel diseases
☐ Crohn’s disease (649)
☐ Ulcerative colitis (650)
☐ Other autoimmune bowel disorder (651) - Go to question 360
CIBMTR Form 2402 revision 4 (page 55 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Metabolic
☐ Diabetes mellitus type 1 (660)
Other
☐ Other autoimmune disease (629) - Go to question 361
359. Specify other autoimmune cytopenia:________________________________________
360. Specify other autoimmune bowel disorder:____________________________________
361. Specify other autoimmune disease:_________________________________________
- Go to signature line
Tolerance Induction Associated with Solid Organ Transplant
362. Specify transplanted organ: (check all that apply)
☐ Kidney
☐ Liver
☐ Pancreas
☐ Other organ
363. Other organ, specify:_____________________________________________________
- Go to signature line
Other Disease
364. Specify other disease:_____________________________________________________________________________ - Go to signature line
First Name:_____________________________________________________
Last Name:______________________________________________________
E-mail address:__________________________________________________
Date: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
CIBMTR Form 2402 revision 4 (page 56 of 56). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
| File Type | application/pdf |
| File Modified | 2019-04-30 |
| File Created | 2019-04-30 |