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Disease Classification
ICR 202007-0915-002 · OMB 0915-0310 · Object 103198801.
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | Disease Classification |
| Author | Monique Ammi |
| Last Modified By | Writer |
| File Modified | 2020-07-17 |
| File Created | 2026-09-14 |
| Conversion State | complete |
Extracted Text
Registry Use Only
Sequence Number:
Date Received:
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Event date: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY MM DD
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 Syndrome (MDS) (50) (If recipient has transformed to AML, indicate AML as the primary disease.) - Go to question 179
• Myeloproliferative Neoplasms (MPN) (1460) (If recipient has transformed to AML, indicate AML as the primary disease.) - Go to question 259
• Other leukemia (30) (includes CLL) - Go to question 372
• Hodgkin lymphoma (150) - Go to question 379
• Non-Hodgkin lymphoma (100) - Go to question 379
• Multiple myeloma / plasma cell disorder (PCD) (170) - Go to question 397
• Solid tumors (200) - Go to question 444
• Aplastic anemia (300) (If the recipient developed MDS or AML, indicate MDS or AML as the primary disease.) - Go to question 446
• Inherited bone marrow failure syndromes (320) (If the recipient developed MDS or AML, indicate MDS or AML as the primary disease.)– Go to question 449
• Hemoglobinopathies (330) - Go to question 451
• Paroxysmal nocturnal hemoglobinuria (PNH) (340) – Go to signature line
• Disorders of the immune system (400) - Go to question 488
• Inherited abnormalities of platelets (500) - Go to question 496
• Inherited disorders of metabolism (520) - Go to question 498
• Histiocytic disorders (570) - Go to question 501
• Autoimmune diseases (600) - Go to question 506
• Tolerance induction associated with solid organ transplant (910) - Go to question 510
• Recessive dystrophic epidermolysis bullosa (920) – Go to First Name
• Other disease (900) - Go to question 512
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
• 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)
4. Did AML transform from MDS or MPN?
• Yes – Also complete MDS or MPN Disease Classification questions
• No
5. Is the disease (AML) therapy related?
• Yes
• No
• Unknown
6. Did the recipient have a predisposing condition?
• Yes - Go to question 7
• No - Go to question 9
• Unknown - Go to question 9
7. Specify condition
• Bloom syndrome - Go to question 9
• Down syndrome - Go to question 9
• Fanconi anemia - Also complete CIBMTR Form 2029 - Go to question 9
• Dyskeratosis congenita - Go to question 9
• Other condition - Go to question 8
8. Specify other condition: __________________________________________
Labs at diagnosis
9. Were cytogenetics tested (karyotyping or FISH)? (at diagnosis)
• Yes - Go to question 10
• No - Go to question 23
• Unknown - Go to question 23
10. Were cytogenetics tested via FISH?
• Yes – Go to question 11
• No - Go to question 16
11. Results of tests
• Abnormalities identified – Go to question 12
• No abnormalities - Go to question 16
Specify cytogenetic abnormalities identified at diagnosis
12. International System for Human Cytogenetic Nomenclature (ISCN) compatible string: ___________________________________
13. Specify number of distinct cytogenetic abnormalities
• One (1)
• Two (2)
• Three (3)
• Four or more (4 or more)
14. Specify abnormalities (check all that apply)
• -5
• -7
• -17
• -18
• -X
• -Y
• +4
• +8
• +11
• +13
• +14
• +21
• +22
• t(3;3)
• t(6;9)
• t(8;21)
• t(9;11)
• t(9;22)
• t(15;17) and variants
• t(16;16)
• del(3q) / 3q–
• del(5q) / 5q–
• del(7q) / 7q–
• del(9q) / 9q–
• del(11q) / 11q–
• del(16q) / 16q–
• del(17q) / 17q–
• del(20q) / 20q–
• del(21q) / 21q–
• inv(3)
• inv(16)
• (11q23) any abnormality
• 12p any abnormality
• Other abnormality - Go to question 15
15. Specify other abnormality: _____________________
16. Were cytogenetics tested via karyotyping?
• Yes – Go to question 17
• No - Go to question 22
17. Results of tests
• Abnormalities identified – Go to question 18
• No evaluable metaphases - Go to question 22
• No abnormalities - Go to question 22
Specify cytogenetic abnormalities identified at diagnosis
18. International System for Human Cytogenetic Nomenclature (ISCN) compatible string: _____________________________
19. Specify number of distinct cytogenetic abnormalities
• One (1)
• Two (2)
• Three (3)
• Four or more (4 or more)
20. Specify abnormalities (check all that apply)
• -5
• -7
• -17
• -18
• -X
• -Y
• +4
• +8
• +11
• +13
• +14
• +21
• +22
• t(3;3)
• t(6;9)
• t(8;21)
• t(9;11)
• t(9;22)
• t(15;17) and variants
• t(16;16)
• del(3q) / 3q–
• del(5q) / 5q–
• del(7q) / 7q–
• del(9q) / 9q–
• del(11q) / 11q–
• del(16q) / 16q–
• del(17q) / 17q–
• del(20q) / 20q–
• del(21q) / 21q–
• inv(3)
• inv(16)
• (11q23) any abnormality
• 12p any abnormality
• Other abnormality - Go to question 21
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 – Go to question 24
• No – Go to question 36
• Unknown – Go to question 36
Specify molecular markers identified at diagnosis
24. CEBPA
• Positive – Go to question 25
• Negative - Go to question 26
• Not done - Go to question 26
25. Specify CEBPA mutation
• Biallelic (homozygous)
• Monoallelic (heterozygous)
• Unknown
26. FLT – TKD (point mutations in D835 or deletions of codon I836)
• Positive
• Negative
• Not done
27. FLT3 – ITD mutation
• Positive- Go to question 28
• Negative- Go to question 30
• Not done- Go to question 30
28. FLT3 – ITD allelic ratio
• Known - Go to question 29
• Unknown - Go to question 30
29. Specify FLT3 - ITD allelic ratio: ___ . ___ ___
30. IDH1
• Positive
• Negative
• Not done
31. IDH2
• Positive
• Negative
• Not done
32. KIT
• Positive
• Negative
• Not done
33. NPM1
• Positive
• Negative
• Not done
34. Other molecular marker
• Positive- Go to question 35
• Negative- Go to question 35
• Not done- Go to question 36
35. Specify other molecular marker: _________________________________
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 - Go to question 37
• No - Go to question 50
• Unknown - Go to question 50
37. Were cytogenetics tested via FISH?
• Yes – Go to question 38
• No - Go to question 43
38. Results of tests
• Abnormalities identified – Go to question 39
• No abnormalities - Go to question 43
Specify cytogenetic abnormalities identified between diagnosis and last evaluation
39. International System for Human Cytogenetic Nomenclature (ISCN) compatible string: ____________________________
40. Specify number of distinct cytogenetic abnormalities
• One (1)
• Two (2)
• Three (3)
• Four or more (4 or more)
41. Specify abnormalities (check all that apply)
• -5
• -7
• -17
• -18
• -X
• -Y
• +4
• +8
• +11
• +13
• +14
• +21
• +22
• t(3;3)
• t(6;9)
• t(8;21)
• t(9;11)
• t(9;22)
• t(15;17) and variants
• t(16;16)
• del(3q) / 3q–
• del(5q) / 5q–
• del(7q) / 7q–
• del(9q) / 9q–
• del(11q) / 11q–
• del(16q) / 16q–
• del(17q) / 17q–
• del(20q) / 20q–
• del(21q) / 21q–
• inv(3)
• inv(16)
• (11q23) any abnormality
• 12p any abnormality
• Other abnormality - Go to question 42
42. Specify other abnormality: _____________________
43. Were cytogenetics tested via karyotyping?
• Yes – Go to question 44
• No - Go to question 49
44. Results of tests
• Abnormalities identified – Go to question 45
• No evaluable metaphases - Go to question 49
• No abnormalities - Go to question 49
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
• One (1)
• Two (2)
• Three (3)
• Four or more (4 or more)
47. Specify abnormalities (check all that apply)
• -5
• -7
• -17
• -18
• -X
• -Y
• +4
• +8
• +11
• +13
• +14
• +21
• +22
• t(3;3)
• t(6;9)
• t(8;21)
• t(9;11)
• t(9;22)
• t(15;17) and variants
• t(16;16)
• del(3q) / 3q–
• del(5q) / 5q–
• del(7q) / 7q–
• del(9q) / 9q–
• del(11q) / 11q–
• del(16q) / 16q–
• del(17q) / 17q–
• del(20q) / 20q–
• del(21q) / 21q–
• inv(3)
• inv(16)
• (11q23) any abnormality
• 12p any abnormality
• Other abnormality - Go to question 48
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 – Go to question 51
• No – Go to question 63
• Unknown – Go to question 63
Specify molecular markers identified between diagnosis and last evaluation
51. CEBPA
• Positive – Go to question 52
• Negative - Go to question 53
• Not done - Go to question 53
52. Specify CEBPA mutation
• Biallelic (homozygous)
• Monoallelic (heterozygous)
• Unknown
53. FLT – TKD (point mutations in D835 or deletions of codon I836)
• Positive
• Negative
• Not done
54. FLT3 – ITD mutation
• Positive- Go to question 55
• Negative- Go to question 57
• Not done- Go to question 57
55. FLT3 – ITD allelic ratio
• Known - Go to question 56
• Unknown - Go to question 57
56. Specify FLT3 - ITD allelic ratio: ___ . ___
57. IDH1
• Positive
• Negative
• Not done
58. IDH2
• Positive
• Negative
• Not done
59. KIT
• Positive
• Negative
• Not done
60. NPM1
• Positive
• Negative
• Not done
61. Other molecular marker:
• Positive- Go to question 62
• Negative- Go to question 62
• Not done- Go to question 63
62. Specify other molecular marker: _________________________________
Copy and complete questions 61-62 to report multiple other molecular markers
Labs at last evaluation
63. Were cytogenetics tested (karyotyping or FISH)? (at last evaluation)
• Yes - Go to question 64
• No - Go to question 77
• Unknown - Go to question 77
64. Were cytogenetics tested via FISH?
• Yes – Go to question 65
• No - Go to question 70
65. Results of tests
• Abnormalities identified – Go to question 66
• No abnormalities - Go to question 70
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–
• del(17q) / 17q–
• del(20q) / 20q–
• del(21q) / 21q–
• inv(3)
• inv(16)
• (11q23) any abnormality
• 12p any abnormality
• Other abnormality - Go to question 69
69. Specify other abnormality: _____________________
70. Were cytogenetics tested via karyotyping?
• Yes – Go to question 71
• No - Go to question 76
71. Results of tests
• Abnormalities identified – Go to question 72
• No evaluable metaphases - Go to question 76
• No abnormalities - Go to question 76
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
• t(3;3)
• t(6;9)
• t(8;21)
• t(9;11)
• t(9;22)
• t(15;17) and variants
• t(16;16)
• del(3q) / 3q–
• del(5q) / 5q–
• del(7q) / 7q–
• del(9q) / 9q–
• del(11q) / 11q–
• del(16q) / 16q–
• del(17q) / 17q–
• del(20q) / 20q–
• del(21q) / 21q–
• inv(3)
• inv(16)
• (11q23) any abnormality
• 12p any abnormality
• Other abnormality - Go to question 75
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 – Go to question 78
• No – Go to question 90
• Unknown – Go to question 90
Specify molecular markers identified at last evaluation
78. CEBPA
• Positive – Go to question 79
• Negative - Go to question 80
• Not done - Go to question 80
79. Specify CEBPA mutation
• Biallelic (homozygous)
• Monoallelic (heterozygous)
• Unknown
80. FLT – TKD (point mutations in D835 or deletions of codon I836)
• Positive
• Negative
• Not done
81. FLT3 – ITD mutation
• Positive- Go to question 82
• Negative- Go to question 84
• Not done- Go to question 84
82. FLT3 – ITD allelic ratio
• Known - Go to question 83
• Unknown - Go to question 84
83. Specify FLT3 - ITD allelic ratio: ___ . ___
84. IDH1
• Positive
• Negative
• Not done
85. IDH2
• Positive
• Negative
• Not done
86. KIT
• Positive
• Negative
• Not done
87. NPM1
• Positive
• Negative
• Not done
88. Other molecular marker
• Positive- Go to question 89
• Negative- Go to question 89
• Not done- Go to question 90
89. Specify other molecular marker: _________________________________
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 / infusion:
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
• 1st relapse – Go to question 94
• 2nd relapse – Go to question 94
• ≥ 3rd relapse – Go to question 94
• No treatment – Go to question 95
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 – Go to question 95
• No – Go to question 95
• Unknown – Go to question 95
• 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
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
• T-cell lymphoblastic leukemia / lymphoma (Precursor T-cell ALL) (196)
• Early T-cell precursor lymphoblastic leukemia (96)
NK cell lymphoblastic leukemia / lymphoma
• Natural killer (NK)- cell lymphoblastic leukemia / lymphoma (97)
97. Did the recipient have a predisposing condition?
• Yes - Go to question 98
• No - Go to question 100
• Unknown - Go to question 100
98. Specify condition
• Aplastic anemia - Go to question 100 Also complete CIBMTR Form 2028 — APL
• Bloom syndrome - Go to question 100
• Down syndrome - Go to question 100
• Fanconi anemia - Go to question 100 Also complete CIBMTR Form 2029 — FAN
• Other condition - Go to question 99
99. Specify other condition: _________________________________________
100. Were tyrosine kinase inhibitors given for therapy at any time prior to the start of the preparative regimen / infusion? (e.g. imatinib mesylate, dasatinib, etc.)
• Yes
• No
Laboratory studies at diagnosis
101. Were cytogenetics tested (karyotyping or FISH)? (at diagnosis)
• Yes - Go to question 102
• No - Go to question 115
• Unknown - Go to question 115
102. Were cytogenetics tested via FISH? (at diagnosis)
• Yes - Go to question 103
• No - Go to question 108
103. Results of tests (at diagnosis)
• Abnormalities identified - Go to question 104
• No abnormalities - Go to question 108
Specify cytogenetic abnormalities identified at diagnosis
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 – Go to question 107
107. Specify other abnormality: _______________________________
108. Were cytogenetics tested via karyotyping? (at diagnosis)
• Yes - Go to question 109
• No - Go to question 114
109. Results of tests (at diagnosis)
• Abnormalities identified - Go to question 110
• No evaluable metaphases - Go to question 114
• No abnormalities - Go to question 114
Specify cytogenetic abnormalities identified at diagnosis
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 – Go to question 113
113. Specify other abnormality: _________________________
114. Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)
• Yes
• No
115. Were tests for molecular markers performed? (e.g. PCR, NGS) (at diagnosis)
• Yes – Go to question 116
• No – Go to question 120
• Unknown – Go to question 120
Specify molecular markers identified at diagnosis
116. BCR / ABL
• Positive
• Negative
• Not done
117. TEL-AML / AML1
• Positive
• Negative
• Not done
118. Other molecular marker
• Positive – Go to question 119
• Negative – Go to question 119
• Not done – Go to question 120
119. Specify other molecular marker: ______________________________
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 - Go to question 121
• No - Go to question 134
• Unknown - Go to question 134
121. Were cytogenetics tested via FISH? (between diagnosis and last evaluation)
• Yes - Go to question 122
• No - Go to question 127
122. Results of tests (between diagnosis and last evaluation)
• Abnormalities identified - Go to question 123
• No abnormalities - Go to question 127
Specify cytogenetic abnormalities identified between diagnosis and last evaluation
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)
• 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 – Go to question 126
126. Specify other abnormality: ___________________________
127. Were cytogenetics tested via karyotyping? (between diagnosis and last evaluation)
• Yes - Go to question 128
• No - Go to question 133
128. Results of tests (between diagnosis and last evaluation)
• Abnormalities identified - Go to question 129
• No evaluable metaphases - Go to question 133
• No abnormalities - Go to question 133
Specify cytogenetic abnormalities identified between diagnosis and last evaluation
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)
• 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 – Go to question 132
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 – Go to question 135
• No – Go to question 139
• Unknown – Go to question 139
Specify molecular markers identified between diagnosis and last evaluation
135. BCR / ABL
• Positive
• Negative
• Not done
136. TEL-AML / AML1
• Positive
• Negative
• Not done
137. Other molecular marker
• Positive – Go to question 138
• Negative – Go to question 138
• Not done – Go to question 139
138. Specify other molecular marker: _________________________
Copy and complete questions 137-138 for additional molecular markers
Laboratory studies at last evaluation
139. Were cytogenetics tested (karyotyping or FISH)? (at last evaluation)
• Yes - Go to question 140
• No - Go to question 153
• Unknown - Go to question 153
140. Were cytogenetics tested via FISH?
• Yes - Go to question 141
• No - Go to question 146
141. Results of tests
• Abnormalities identified - Go to question 142
• No abnormalities - Go to question 146
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 – Go to question 145
145. Specify other abnormality: ____________________
146. Were cytogenetics tested via karyotyping? (at last evaluation)
• Yes - Go to question 147
• No - Go to question 152
147. Results of tests
• Abnormalities identified - Go to question 148
• No evaluable metaphases - Go to question 152
• No abnormalities - Go to question 152
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 – Go to question 151
151. Specify other abnormality: ____________________
152. Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)
• Yes
• No
153. Were tests for molecular markers performed? (e.g. PCR, NGS) (at last evaluation)
• Yes – Go to question 154
• No – Go to question 158
• Unknown – Go to question 158
Specify molecular markers identified at last evaluation
154. BCR / ABL
• Positive
• Negative
• Not done
155. TEL-AML / AML1
• Positive
• Negative
• Not done
156. Other molecular marker
• Positive – Go to question 157
• Negative – Go to question 157
• Not done – Go to question 158
157. Specify other molecular marker: ___________________________
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 / infusion
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
• 1st relapse – Go to question 162
• 2nd relapse – Go to question 162
• ≥ 3rd relapse – Go to question 162
• No treatment – Go to question 163
160. How many cycles of induction therapy were required to achieve 1st complete remission? (include CRi)
• 1
• 2
• ≥ 3
161. Was the recipient in remission by flow cytometry?
• Yes – Go to question 163
• No – Go to question 163
• Unknown – Go to question 163
• 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) – Go to question 166
• Acute undifferentiated leukemia (31) – Go to question 166
• Mixed phenotype acute leukemia (MPAL) with t(9;22)(q34.1;q11.2); BCR-ABL1 (84) – Go to question 166
• Mixed phenotype acute leukemia with t(v; 11q23.3); KMT2A rearranged (85) – Go to question 166
• Mixed phenotype acute leukemia, B/myeloid, NOS (86) – Go to question 166
• Mixed phenotype acute leukemia, T/myeloid, NOS (87) – Go to question 166
• Other acute leukemia of ambiguous lineage or myeloid neoplasm (88) - Go to question 165
165. Specify other acute leukemia of ambiguous lineage or myeloid neoplasm: __________________
Status at transplantation / infusion
166. What was the disease status? (based on hematological test results)
• Primary induction failure
• 1st complete remission (no previous marrow or extramedullary relapse)
• 2nd complete remission
• ≥ 3rd complete remission
• 1st relapse
• 2nd relapse
• ≥3rd relapse
• No treatment
167. Date assessed: ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to signature line
YYYY MM DD
Chronic Myelogenous Leukemia (CML)
168. Was therapy given prior to this HCT?
• Yes - Go to question 169
• No - Go to question 175
169. Combination chemotherapy
• Yes
• No
170. Hydroxyurea (Droxia, Hydrea)
• Yes
• No
171. Tyrosine kinase inhibitor (e.g.imatinib mesylate, dasatinib, nilotinib)
• Yes
• No
172. Interferon-α (Intron, Roferon) (includes PEG)
• Yes
• No
173. Other therapy
• Yes - Go to question 174
• No - Go to question 175
174. Specify other therapy: ______________________________________
175. What was the disease status?
• Complete hematologic response (CHR) preceded only by chronic phase- Go to question 176
• Complete hematologic response (CHR) preceded by accelerated phase and/or blast phase- Go to question 176
• Chronic phase – Go to question 176
• Accelerated phase - Go to question 177
• Blast phase - Go to question 177
176. Specify level of response
• No cytogenetic response (No CyR)
• Minimal cytogenetic response
• Minor cytogenetic response
• Partial cytogenetic response (PCyR)
• Complete cytogenetic response (CCyR)
• Major molecular remission (MMR)
• Complete molecular remission (CMR)
177. Number
• 1st
• 2nd
• 3rd or higher
178. Date assessed: ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to signature line
YYYY MM DD
Myelodysplastic Syndrome (MDS)
179. What was the MDS subtype at diagnosis? – If transformed to AML, indicate AML as primary disease; also complete AML Disease Classification questions
• Atypical chronic myeloid leukemia (aCML), BCR-ABL1 (1440) – Go to question 376
• Chronic myelomonocytic leukemia (CMMoL) (54) – Go to question 182
• Juvenile myelomonocytic leukemia (JMML) (36) – Go to question 218
• Myelodysplastic syndrome / myeloproliferative neoplasm, unclassifiable (69) – Go to question 181
• MDS / MPN with ring sideroblasts and thrombocytosis (MDS / MPN–RS–T) (1452) – Go to question 182
• Myelodysplastic syndrome (MDS), unclassifiable (50)– Go to question 180
• Myelodysplastic syndrome with isolated del(5q) (66)– Go to question 182
• Myelodysplastic syndrome with multilineage dysplasia (MDS-MLD) (64) – Go to question 182
• Myelodysplastic syndrome with single lineage dysplasia (MDS-SLD) (51) – Go to question 182
• Refractory cytopenia of childhood (68)– Go to question 182
Myelodysplastic syndrome with excess blasts (MDS-EB)
• MDS with excess blasts-1 (MDS-EB-1) (61) – Go to question 182
• MDS with excess blasts-2 (MDS-EB-2) (62) – Go to question 182
Myelodysplastic syndrome with ring sideroblasts (MDS-RS)
• MDS-RS with single lineage dysplasia (MDS-RS-SLD) (1453) – Go to question 182
• MDS-RS with multilineage dysplasia (MDS-RS-MLD) (1454) – Go to question 182
180. Specify Myelodysplastic syndrome, unclassifiable (MDS-U)
• MDS-U with 1% blood blasts
• MDS-U with single lineage dysplasia and pancytopenia
• MDS-U based on defining cytogenetic abnormality
181. Was documentation submitted to the CIBMTR? (e.g. pathology report used for diagnosis)
• Yes
• No
182. Was the disease MDS therapy related?
• Yes
• No
• Unknown
183. Did the recipient have a predisposing condition?
• Yes – Go to question 184
• No – Go to question 186
• Unknown – Go to question 186
184. Specify condition
• Aplastic anemia – Go to question 186
• DDX41-associated familial MDS – Go to question 186
• Diamond-Blackfan Anemia – Go to question 186
• Fanconi anemia –Go to question 186
• GATA2 deficiency (including Emberger syndrome, MonoMac syndrome, DCML deficiency) – Go to question 186
• Li-Fraumeni Syndrome – Go to question 186
• Paroxysmal nocturnal hemoglobinuria – Go to question 186
• RUNX1 deficiency (previously “familial platelet disorder with propensity to myeloid malignancies”) – Go to question 186
• SAMD9- or SAMD9L-associated familial MDS – Go to question 186
• Shwachman-Diamond Syndrome – Go to question 186
• Telomere biology disorder (including dyskeratosis congenita) – Go to question 186
• Other condition – Go to question 185
185. Specify other condition: _______________________
Laboratory studies at diagnosis of MDS
186. Date CBC drawn: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY MM DD
187. WBC
• Known – Go to question 188
• Unknown – Go to question 189
188. ___ ___ ___ ___ ___ ___ ● ___ x 109/L (x 103/mm3)
x 106/L
189. Neutrophils
• Known – Go to question 190
• Unknown – Go to question 191
190. ___ ___%
191. Blasts in blood
• Known – Go to question 192
• Unknown– Go to question 193
192. ___ ___ ___ %
193. Hemoglobin
• Known – Go to question 194
• Unknown – Go to question 196
194. ___ ___ ___ ___ ● ___ ___ g/dL
3. g/L
4. mmol/L
195. Were RBCs transfused ≤ 30 days before date of test?
• Yes
• No
196. Platelets
• Known – Go to question 197
• Unknown – Go to question 199
197. ___ ___ ___ ___ ___ ___ ___ x 109/L (x 103/mm3)
x 106/L
198. Were platelets transfused ≤ 7 days before date of test?
• Yes
• No
199. Blasts in bone marrow
• Known – Go to question 200
• Unknown – Go to question 201
200. ___ ___ ___ %
201. Were cytogenetics tested (karyotyping or FISH)?
• Yes – Go to question 202
• No – Go to question 218
• Unknown – Go to question 218
202. Were cytogenetics tested via FISH?
• Yes- Go to question 203
• No- Go to question 210
203. Sample source
• Blood
• Bone marrow
204. Results of tests
• Abnormalities identified – Go to question 205
• No abnormalities – Go to question 209
Specify cytogenetic abnormalities identified via FISH at diagnosis
205. International System for Human Cytogenetic Nomenclature (ISCN) compatible string: __________________________
206. Specify number of distinct cytogenetic abnormalities
• One (1)
• Two (2)
• Three (3)
• Four or more (4 or more)
207. 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 – Go to question 208
208. Specify other abnormality:__________________________
209. Was documentation submitted to the CIBMTR? (e.g. FISH report)
• Yes
• No
210. Were cytogenetics tested via karyotyping?
• Yes- Go to question 211
• No- Go to question 218
211. Sample source
• Blood
• Bone marrow
212. Results of tests
• Abnormalities identified – Go to question 213
• No evaluable metaphases- Go to question 217
• No abnormalities – Go to question 217
Specify cytogenetic abnormalities identified via conventional cytogenetics at diagnosis
213. International System for Human Cytogenetic Nomenclature (ISCN) compatible string: __________________________
214. Specify number of distinct cytogenetic abnormalities
• One (1)
• Two (2)
• Three (3)
• Four or more (4 or more)
215. 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 – Go to question 216
216. Specify other abnormality:__________________________
217. Was documentation submitted to the CIBMTR? (e.g. karyotyping report)
• Yes
• No
218. Did the recipient progress or transform to a different MDS subtype or AML between diagnosis and the start of the preparative regimen / infusion?
• Yes – Go to question 219
• No – Go to question 223
219. Specify the MDS subtype or AML after transformation
• Chronic myelomonocytic leukemia (CMMoL) (54) – Go to question 221
• Myelodysplastic syndrome / myeloproliferative neoplasm, unclassifiable (69) – Go to question 221
• MDS / MPN with ring sideroblasts and thrombocytosis (MDS / MPN–RS–T) (1452) – Go to question 221
• Myelodysplastic syndrome (MDS), unclassifiable (50) – Go to question 220
• Myelodysplastic syndrome with isolated del(5q) (66) – Go to question 221
• Myelodysplastic syndrome with multilineage dysplasia (MDS-MLD) (64) – Go to question 221
• Myelodysplastic syndrome with single lineage dysplasia (MDS-SLD)) (51) – Go to question 221
• Refractory cytopenia of childhood (68) – Go to question 221
• Transformed to AML (70) – Go to question 222
Myelodysplastic syndrome with excess blasts (MDS-EB)
• MDS with excess blasts-1 (MDS-EB-1) (61) – Go to question 221
• MDS with excess blasts-2 (MDS-EB-2) (62) – Go to question 221
Myelodysplastic syndrome with ring sideroblasts
• MDS-RS with single lineage dysplasia (MDS-RS-SLD) (1453) – Go to question 221
• MDS-RS with multilineage dysplasia (MDS-RS-MLD) (1454) – Go to question 221
220. Specify Myelodysplastic syndrome, unclassifiable (MDS-U)
• MDS-U with 1% blood blasts– Go to question 221
• MDS-U with single lineage dysplasia and pancytopenia– Go to question 221
• MDS-U based on defining cytogenetic abnormality– Go to question 221
221. Specify the date of the most recent transformation:___ ___ ___ ___ — ___ ___ — ___ ___ - Go to question 223
222. Date of MDS diagnosis: ___ ___ ___ ___ - ___ ___ - ___ ___ – Go to signature line
Laboratory studies at last evaluation prior to the start of the preparative regimen / infusion
223. Date CBC drawn: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY MM DD
224. WBC
• Known – Go to question 225
• Unknown – Go to question 226
225. ___ ___ ___ ___ ___ ___ ● ___ x 109/L (x 103/mm3)
x 106/L
226. Neutrophils
• Known – Go to question 227
• Unknown – Go to question 228
227. ___ ___%
228. Blasts in blood
• Known – Go to question 229
• Unknown – Go to question 230
229. ___ ___ ___ %
230. Hemoglobin
• Known – Go to question 231
• Unknown – Go to question 233
231. ___ ___ ___ ___ ● ___ ___ g/dL
5. g/L
6. mmol/L
232. Were RBCs transfused ≤ 30 days before date of test?
• Yes
• No
233. Platelets
• Known – Go to question 234
• Unknown – Go to question 236
234. ___ ___ ___ ___ ___ ___ ___ x 109/L (x 103/mm3)
x 106/L
235. Were platelets transfused ≤ 7 days before date of test?
• Yes
• No
236. Blasts in bone marrow
• Known – Go to question 237
• Unknown – Go to question 238
237. ___ ___ ___ %
238. Were cytogenetics tested (karyotyping or FISH)?
• Yes – Go to question 239
• No – Go to question 255
• Unknown – Go to question 255
239. Were cytogenetics tested via FISH?
• Yes- Go to question 240
• No- Go to question 247
240. Sample source
• Blood
• Bone marrow
241. Results of tests
• Abnormalities identified – Go to question 242
• No abnormalities – Go to question 246
Specify cytogenetic abnormalities identified via FISH at last evaluation prior to the start of the preparative regimen / infusion
242. International System for Human Cytogenetic Nomenclature (ISCN) compatible string: __________________________
243. Specify number of distinct cytogenetic abnormalities
• One (1)
• Two (2)
• Three (3)
• Four or more (4 or more)
244. 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 – Go to question 245
245. Specify other abnormality:__________________________
246. Was documentation submitted to the CIBMTR? (e.g. FISH report)
• Yes
• No
247. Were cytogenetics tested via karyotyping?
• Yes- Go to question 248
• No- Go to question 255
248. Sample source
• Blood
• Bone marrow
249. Results of tests
• Abnormalities identified – Go to question 250
• No evaluable metaphases- Go to question 254
• No abnormalities – Go to question 254
Specify cytogenetic abnormalities identified via conventional cytogenetics at last evaluation prior to the start of the preparative regimen / infusion
250. International System for Human Cytogenetic Nomenclature (ISCN) compatible string: __________________________
251. Specify number of distinct cytogenetic abnormalities
• One (1)
• Two (2)
• Three (3)
• Four or more (4 or more)
252. 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 – Go to question 253
253. Specify other abnormality:__________________________
254. Was documentation submitted to the CIBMTR? (e.g. karyotyping report)
• Yes
• No
Status at transplantation / infusion
255. What was the disease status?
• Complete remission (CR) –- Go to question 258
• Hematologic improvement (HI) – Go to question 256
• No response (NR) / stable disease (SD) – Go to question 258
• Progression from hematologic improvement (Prog from HI) - Go to question 258
• Relapse from complete remission (Rel from CR) - Go to question 258
• Not assessed - Go to signature line
256. Specify the cell line examined to determine HI status (check all that apply)
• HI-E –- Go to question 257
• HI-P – Go to question 258
• HI-N – Go to question 258
257. Specify transfusion dependence
• Non transfused (NTD)-– Go to question 258
• Low transfusion burden (LTB)- Go to question 258
258. Date assessed: ___ ___ ___ ___ — ___ ___ — ___ ___- Go to signature line
YYYY MM DD
Myeloproliferative Neoplasms (MPN)
259. What was the MPN subtype at diagnosis? – If transformed to AML, indicate AML as primary disease; also complete AML Disease Classification questions
• Chronic neutrophilic leukemia (165) –Go to Question 262
• Chronic eosinophilic leukemia, not otherwise specified (NOS) (166) – Go to Question 262
• Essential thrombocythemia (58) – Go to Question 262
• Myeloproliferative neoplasm (MPN), unclassifiable (60) – Go to Question 260
• Myeloid / lymphoid neoplasms with PDGFRA rearrangement (1461) – Go to Question 262
• Myeloid / lymphoid neoplasms with PDGFRB rearrangement (1462) – Go to Question 262
• Myeloid / lymphoid neoplasms with FGFR1 rearrangement (1463) – Go to Question 262
• Myeloid / lymphoid neoplasms with PCM1-JAK2 (1464) – Go to Question 262
• Polycythemia vera (PCV) (57) – Go to Question 262
• Primary myelofibrosis (PMF) (167)- Go to Question 262
Mastocytosis
• Cutaneous mastocytosis (CM) (1465) – Go to Question 262
• Systemic mastocytosis (1470) - Go to Question Error! Reference source not found.
• Mast cell sarcoma (MCS) (1466) – Go to Question 262
260. Specify systemic mastocytosis
• Indolent systemic mastocytosis (ISM) – Go to Question 262
• Smoldering systemic mastocytosis (SSM) – Go to question 262
• Systemic mastocytosis with an associated hematological neoplasm (SM-AHN) – Go to question 262
• Aggressive systemic mastocytosis (ASM) – Go to question 262
• Mast cell leukemia (MCL) – Go to question 262
261. Was documentation submitted to the CIBMTR? (e.g. pathology report used for diagnosis)
• Yes
• No
Assessment at diagnosis
262. Did the recipient have constitutional symptoms in six months before diagnosis? (symptoms are >10% weight loss in 6 months, night sweats, or unexplained fever higher than 37.5 °C)
• Yes
• No
• Unknown
Laboratory studies at diagnosis of MPN
263. Date CBC drawn: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY MM DD
264. WBC
• Known – Go to question 265
• Unknown – Go to question 266
265. ___ ___ ___ ___ ___ ___ ● ___ x 109/L (x 103/mm3)
x 106/L
266. Neutrophils
• Known – Go to question 267
• Unknown – Go to question 268
267. ___ ___%
268. Blasts in blood
• Known – Go to question 269
• Unknown– Go to question 270
269. ___ ___ ___ %
270. Hemoglobin
• Known – Go to question 271
• Unknown – Go to question 273
271. ___ ___ ___ ___ ● ___ ___ g/dL
7. g/L
8. mmol/L
272. Were RBCs transfused ≤ 30 days before date of test?
• Yes
• No
273. Platelets
• Known – Go to question 274
• Unknown – Go to question 276
274. ___ ___ ___ ___ ___ ___ ___ x 109/L (x 103/mm3)
x 106/L
275. Were platelets transfused ≤ 7 days before date of test?
• Yes
• No
276. Blasts in bone marrow
• Known – Go to question 277
• Unknown – Go to question 278
277. ___ ___ ___ %
278. Were tests for driver mutations performed?
• Yes – Go to question 279
• No – Go to question 289
• Unknown - Go to question 289
279. JAK2
• Positive– Go to question 280
• Negative– Go to question 282
• Not done– Go to question 282
280. JAK2 V617F
• Positive
• Negative
• Not done
281. JAK2 Exon 12
• Positive
• Negative
• Not done
282. CALR
• Positive – Go to question 283
• Negative– Go to question 286
• Not done– Go to question 286
283. CALR type 1
• Positive
• Negative
• Not done
284. CALR type 2
• Positive
• Negative
• Not done
285. Not defined
• Positive
• Negative
• Not done
286. MPL
• Positive
• Negative
• Not done
287. CSF3R
• Positive
• Negative
• Not done
288. Was documentation submitted to the CIBMTR?
• Yes
• No
289. Were cytogenetics tested (karyotyping or FISH)?
• Yes – Go to question 290
• No – Go to question 306
• Unknown – Go to question 306
290. Were cytogenetics tested via FISH?
• Yes- Go to question 291
• No- Go to question 298
291. Sample source
• Blood
• Bone marrow
292. Results of tests
• Abnormalities identified – Go to question 293
• No abnormalities – Go to question 297
Specify cytogenetic abnormalities identified via FISH at diagnosis:
293. International System for Human Cytogenetic Nomenclature (ISCN) compatible string: __________________________
294. Specify number of distinct cytogenetic abnormalities
• One (1)
• Two (2)
• Three (3)
• Four or more (4 or more)
295. Specify abnormalities (check all that apply)
Monosomy
• –5
• –7
• –Y
Trisomy
• +8
• +9
Translocation
• t(1;any)
• t(3q21;any)
• t(11q23;any)
• t(12p11.2;any)
• t(6;9)
Deletion
• del(5q) / 5q-
• del(7q) / 7q-
• del(11q) / 11q-
• del(12p) / 12p-
• del(13q) / 13q-
• del(20q) / 20q-
Inversion
• dup(1)
• inv(3)
Other
• i17q
• Other abnormality – Go to question 296
296. Specify other abnormality:__________________________
297. Was documentation submitted to the CIBMTR? (e.g. FISH report)
• Yes
• No
298. Were cytogenetics tested via karyotyping?
• Yes- Go to question 299
• No- Go to question 306
299. Sample source
• Blood
• Bone marrow
300. Results of tests
• Abnormalities identified – Go to question 301
• No evaluable metaphases- Go to question 305
• No abnormalities – Go to question 305
Specify cytogenetic abnormalities identified via conventional cytogenetics at diagnosis
301. International System for Human Cytogenetic Nomenclature (ISCN) compatible string: __________________________
302. Specify number of distinct cytogenetic abnormalities
• One (1)
• Two (2)
• Three (3)
• Four or more (4 or more)
303. Specify abnormalities (check all that apply)
Monosomy
• –5
• –7
• –Y
Trisomy
• +8
• +9
Translocation
• t(1;any)
• t(3q21;any)
• t(11q23;any)
• t(12p11.2;any)
• t(6;9)
Deletion
• del(5q) / 5q-
• del(7q) / 7q-
• del(11q) / 11q-
• del(12p) / 12p-
• del(13q) / 13q-
• del(20q) / 20q-
Inversion
• dup(1)
• inv(3)
Other
• i17q
• Other abnormality – Go to question 304
304. Specify other abnormality:__________________________
305. Was documentation submitted to the CIBMTR? (e.g. karyotyping report)
• Yes
• No
306. Did the recipient progress or transform to a different MPN subtype or AML between diagnosis and the start of the preparative regimen / infusion?
• Yes – Go to question 307
• No – Go to question 310
307. Specify the MPN subtype or AML after transformation
• Post-essential thrombocythemic myelofibrosis (1467) – Go to question 308
• Post-polycythemic myelofibrosis (1468) – Go to question 308
• Transformed to AML (70) – Go to question 309
308. Specify the date of the most recent transformation:___ ___ ___ ___ — ___ ___ — ___ ___ - Go to question 310
309. Date of MPN diagnosis: ___ ___ ___ ___ - ___ ___ - ___ ___ – Go to signature line
YYYY MM DD
Assessment at last evaluation prior to the start of the preparative regimen/ infusion
310. Specify transfusion dependence at last evaluation prior to the start of the preparative regimen/ infusion
• Non-transfused (NTD) –(0 RBCs in 16 weeks)
• Low-transfusion burden (LTB) -(3-7 RBCs in 16 weeks in at least 2 transfusion episodes; maximum of 3 in 8 weeks)
• High-transfusion burden (HTB) - (≥ 8 RBCs in 16weeks; ≥ 4 in 8 weeks)
311. Did the recipient have constitutional symptoms in six months before last evaluation prior to the start of the preparative regimen / infusion? (symptoms are >10% weight loss in 6 months, night sweats, or unexplained fever higher than 37.5 °C)
• Yes
• No
• Unknown
312. Did the recipient have splenomegaly at last evaluation prior to the start of the preparative regimen/ infusion?
• Yes – Go to question 313
• No – Go to question 316
• Unknown- Go to question 316
• Not applicable (splenectomy) – Go to question 316
313. Specify the method used to measure spleen size
• Physical assessment- Go to question 314
• Ultrasound- Go to question 315
• CT/ MRI- Go to question 315
314. Specify the spleen size: ___ ___ centimeters below left costal margin – Go to question 317
315. Specify the spleen size:___ ___ centimeters
316. Did the recipient have hepatomegaly at last evaluation prior to the start of the preparative regimen/infusion?
• Yes – Go to question 317
• No – Go to question 320
• Unknown – Go to question 320
317. Specify the method used to measure liver size
• Physical assessment- Go to question 318
• Ultrasound- Go to question 319
• CT/ MRI- Go to question 319
318. Specify the liver size: ___ ___ centimeters below right costal margin – Go to question 321
319. Specify the liver size: ___ ___ centimeters
Laboratory studies at last evaluation prior to the start of the preparative regimen / infusion
320. Date CBC drawn: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY MM DD
321. WBC
• Known – Go to question 322
• Unknown – Go to question 323
322. ___ ___ ___ ___ ___ ___ ● ___ x 109/L (x 103/mm3)
x 106/L
323. Neutrophils
• Known – Go to question 324
• Unknown – Go to question 325
324. ___ ___%
325. Blasts in blood
• Known – Go to question 326
• Unknown– Go to question 327
326. ___ ___ ___ %
327. Hemoglobin
• Known – Go to question 328
• Unknown – Go to question 330
328. ___ ___ ___ ___ ● ___ ___ g/dL
9. g/L
10. mmol/L
329. Were RBCs transfused ≤ 30 days before date of test?
• Yes
• No
330. Platelets
• Known – Go to question 331
• Unknown – Go to question 333
331. ___ ___ ___ ___ ___ ___ ___ x 109/L (x 103/mm3)
x 106/L
332. Were platelets transfused ≤ 7 days before date of test?
• Yes
• No
333. Blasts in bone marrow
• Known – Go to question 334
• Unknown – Go to question 335
334. ___ ___ ___ %
335. Were tests for driver mutations performed?
• Yes – Go to question 336
• No – Go to question 346
• Unknown - Go to question 346
336. JAK2
• Positive– Go to question 337
• Negative– Go to question 339
• Not done– Go to question 339
337. JAK2 V617F
• Positive
• Negative
• Not Done
338. JAK2 Exon 12
• Positive
• Negative
• Not done
339. CALR
• Positive – Go to question 340
• Negative– Go to question 343
• Not done– Go to question 343
340. CALR type 1
• Positive
• Negative
• Not done
341. CALR type 2
• Positive
• Negative
• Not done
342. Not defined
• Positive
• Negative
• Not done
343. MPL
• Positive
• Negative
• Not done
344. CSF3R
• Positive
• Negative
• Not done
345. Was documentation submitted to the CIBMTR?
• Yes
• No
346. Were cytogenetics tested (karyotyping or FISH)?
• Yes – Go to question 347
• No – Go to question 363
• Unknown – Go to question 363
347. Were cytogenetics tested via FISH?
• Yes- Go to question 348
• No- Go to question 355
348. Sample source
• Blood
• Bone marrow
349. Results of tests
• Abnormalities identified – Go to question 350
• No abnormalities – Go to question 354
Specify cytogenetic abnormalities identified via FISH at last evaluation prior to the start of the preparative regimen / infusion
350. International System for Human Cytogenetic Nomenclature (ISCN) compatible string: __________________________
351. Specify number of distinct cytogenetic abnormalities
• One (1)
• Two (2)
• Three (3)
• Four or more (4 or more)
352. Specify abnormalities (check all that apply)
Monosomy
• –5
• –7
• –Y
Trisomy
• +8
• +9
Translocation
• t(1;any)
• t(3q21;any)
• t(11q23;any)
• t(12p11.2;any)
• t(6;9)
Deletion
• del(5q) / 5q-
• del(7q) / 7q-
• del(11q) / 11q-
• del(12p) / 12p-
• del(13q) / 13q-
• del(20q) / 20q-
Inversion
• dup(1)
• inv(3)
Other
• i17q
• Other abnormality – Go to question 353
353. Specify other abnormality:__________________________
354. Was documentation submitted to the CIBMTR? (e.g. FISH report)
• Yes
• No
355. Were cytogenetics tested via karyotyping?
• Yes- Go to question 356
• No- Go to question 363
356. Sample source
• Blood
• Bone marrow
357. Results of tests
• Abnormalities identified – Go to question 358
• No evaluable metaphases- Go to question 362
• No abnormalities – Go to question 362
Specify cytogenetic abnormalities identified via conventional cytogenetics at last evaluation prior to the start of the preparative regimen / infusion
358. International System for Human Cytogenetic Nomenclature (ISCN) compatible string: __________________________
359. Specify number of distinct cytogenetic abnormalities
• One (1)
• Two (2)
• Three (3)
• Four or more (4 or more)
360. Specify abnormalities (check all that apply)
Monosomy
• –5
• –7
• –Y
Trisomy
• +8
• +9
Translocation
• t(1;any)
• t(3q21;any)
• t(11q23;any)
• t(12p11.2;any)
• t(6;9)
Deletion
• del(5q) / 5q-
• del(7q) / 7q-
• del(11q) / 11q-
• del(12p) / 12p-
• del(13q) / 13q-
• del(20q) / 20q-
Inversion
• dup(1)
• inv(3)
Other
• i17q
• Other abnormality – Go to question 361
361. Specify other abnormality:__________________________
362. Was documentation submitted to the CIBMTR? (e.g. karyotyping report)
• Yes
• No
Status at transplantation / infusion
363. What was the disease status?
• Complete clinical remission (CR) - Go to question 367
• Partial clinical remission (PR) –- Go to question 367
• Clinical improvement (CI) - Go to question 364
• Stable disease (SD)- Go to question 367
• Progressive disease - Go to question 367
• Relapse- Go to question 367
• Not assessed - Go to question 368
364. Was an anemia response achieved?
• Yes
• No
365. Was a spleen response achieved?
• Yes
• No
366. Was a symptom response achieved?
• Yes
• No
367. Date assessed: ___ ___ ___ ___ — ___ ___ — ___ ___- Go to question 368
YYYY MM DD
368. Specify the cytogenetic response
• Complete response (CR): Eradication of pre-existing abnormality – Go to question 369
• Partial response (PR): ≥ 50% reduction in abnormal metaphases – Go to question 369
• Re-emergence of pre-existing cytogenetic abnormality – Go to question 369
• Not assessed – Go to question 370
• Not applicable – Go to question 370
• None of the above: Does not meet the CR or PR criteria – Go to question 369
369. Date assessed: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY MM DD
370. Specify the molecular response
• Complete response (CR): Eradication of pre-existing abnormality – Go to question 371
• Partial response (PR): ≥50% decrease in allele burden – Go to question 371
• Re-emergence of a pre-existing molecular abnormality – Go to question 371
• Not assessed – Go to First Name
• Not applicable – Go to First Name
• None of the above: Does not meet the CR or PR criteria – Go to 371
371. Date assessed: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY MM DD
Other Leukemia (OL)
372. Specify the other leukemia classification
• Chronic lymphocytic leukemia (CLL), NOS (34) - Go to question 374
• Chronic lymphocytic leukemia (CLL), B-cell / small lymphocytic lymphoma (SLL) (71) - Go to question 374
• Hairy cell leukemia (35) - Go to question 377
• Hairy cell leukemia variant (75) - Go to question 377
• Monoclonal B-cell lymphocytosis (76) – Go to signature line
• Prolymphocytic leukemia (PLL), NOS (37) - Go to question 374
• PLL, B-cell (73) - Go to question 374
• PLL, T-cell (74) - Go to question 374
• Other leukemia, NOS (30) - Go to question 376
• Other leukemia (39) - Go to question 373
373. Specify other leukemia: _________________________________– Go to question 376
374. Was any 17p abnormality detected?
• Yes – If disease classification is CLL, go to question 375. If PLL, go to question 377
• No
375. Did a histologic transformation to diffuse large B-cell lymphoma (Richter syndrome) occur at any time after CLL diagnosis?
• Yes – Go to question 379– Also complete NHL Disease Classification questions
• No – Go to question 377
Status at transplantation / infusion:
376. What was the disease status? (Atypical CML)
• Primary induction failure – Go to question 378
• 1st complete remission (no previous bone marrow or extramedullary relapse) – Go to question 378
• 2nd complete remission – Go to question 378
• ≥ 3rd complete remission – Go to question 378
• 1st relapse – Go to question 378
• 2nd relapse – Go to question 378
• ≥ 3rd relapse – Go to question 378
• No treatment – Go to signature line
377. What was the disease status? (CLL, PLL, Hairy cell leukemia)
• Complete remission (CR) – Go to question 378
• Partial remission (PR) – Go to question 378
• Stable disease (SD) – Go to question 378
• Progressive disease (Prog) – Go to question 378
• Untreated - Go to question 378
• Not assessed - Go to signature line
378. Date assessed: ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to signature line
YYYY MM DD
Hodgkin and Non-Hodgkin Lymphoma
379. 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 381
• Diffuse, large B-cell lymphoma- Germinal center B-cell type (1820) - Go to question 381
• 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)
• 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 380
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 380
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)
380. Specify other lymphoma histology: ______________________– Go to question 382
381. 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
• Unknown method
382. Is the lymphoma histology reported at transplant a transformation from CLL?
• Yes – Go to question 383
• No - Go to question 384
383. Was any 17p abnormality detected?
• Yes– Go to question 388
• No– Go to question 388
384. Is the lymphoma histology reported at transplant a transformation from a different lymphoma histology? (Not CLL)
• Yes – Go to question 385
• No – Go to question 388
385. Specify the original lymphoma histology (prior to transformation) _________________
386. Specify other lymphoma histology:________________
387. Date of original lymphoma diagnosis:___ ___ ___ ___ - ___ ___ - ___ ___ (report the date of diagnosis of original lymphoma subtype)
388. Was a PET (or PET/CT) scan performed? (at last evaluation prior to the start of the preparative regimen / infusion)
• Yes – Go to question 389
• No – Go to question 394
389. Was the PET (or PET/CT) scan positive for lymphoma involvement at any disease site?
• Yes
• No
390. Date of PET scan
• Known– Go to question 391
• Unknown – Go to question 392
391. Date of PET (or PET/CT) scan: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY MM DD
392. Deauville (five-point) score of the PET (or PET/CT) scan
• Known – Go to question 393
• Unknown – Go to question 394
393. 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:
394. 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 395
• PIF sen / PR1 - Primary induction failure – sensitive: NEVER in COMPLETE remission but with partial remission on treatment. – Go to question 395
• PIF unk - Primary induction failure – sensitivity unknown– Go to question 395
• CR1 - 1st complete remission: no bone marrow or extramedullary relapse prior to transplant– Go to question 395
• CR2 - 2nd complete remission– Go to question 395
• CR3+ - 3rd or subsequent complete remission– Go to question 395
• REL1 unt - 1st relapse – untreated; includes either bone marrow or extramedullary relapse– Go to question 395
• REL1 res - 1st relapse – resistant: stable or progressive disease with treatment– Go to question 395
• REL1 sen - 1st relapse – sensitive: partial remission (if complete remission was achieved, classify as CR2) – Go to question 395
• REL1 unk - 1st relapse – sensitivity unknown– Go to question 395
• REL2 unt - 2nd relapse – untreated: includes either bone marrow or extramedullary relapse– Go to question 395
• REL2 res - 2nd relapse – resistant: stable or progressive disease with treatment– Go to question 395
• REL2 sen - 2nd relapse – sensitive: partial remission (if complete remission achieved, classify as CR3+)– Go to question 395
• REL2 unk - 2nd relapse – sensitivity unknown– Go to question 395
• REL3+ unt - 3rd or subsequent relapse – untreated; includes either bone marrow or extramedullary relapse– Go to question 395
• REL3+ res - 3rd or subsequent relapse – resistant: stable or progressive disease with treatment– Go to question 395
• REL3+ sen - 3rd or subsequent relapse – sensitive: partial remission (if complete remission achieved, classify as CR3+)– Go to question 395
• REL3+ unk - 3rd relapse or greater – sensitivity unknown– Go to question 395
395. Total number of lines of therapy received (between diagnosis and HCT / infusion)
• 1 line
• 2 lines
• 3+ lines
396. Date assessed: ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to signature line
YYYY MM DD
Multiple Myeloma / Plasma Cell Disorder (PCD)
397. Specify the multiple myeloma/plasma cell disorder (PCD) classification
• Multiple myeloma (178) – Go to question 399
• Multiple myeloma-light chain only (186) - Go to question 399
• Multiple myeloma-non-secretory (187) - Go to question 405
• Plasma cell leukemia (172) - Go to question 407
• Solitary plasmacytoma (no evidence of myeloma) (175) - Go to question 404
• Smoldering myeloma (180) – Go to question 407
• Amyloidosis (174) - Go to question 400
• Osteosclerotic myeloma / POEMS syndrome (176) - Go to question 407
• Monoclonal gammopathy of renal significance (MGRS) (1611) – Go to question 401
• Other plasma cell disorder (179) - Go to question 398
398. Specify other plasma cell disorder: _________________________ - Go to question 407
399. Specify heavy and/or light chain type (check all that apply)
• IgG kappa – Go to question 405
• IgA kappa – Go to question 405
• IgM kappa – Go to question 405
• IgD kappa – Go to question 405
• IgE kappa – Go to question 405
• IgG lambda – Go to question 405
• IgA lambda – Go to question 405
• IgM lambda – Go to question 405
• IgD lambda – Go to question 405
• IgE lambda – Go to question 405
• IgG (heavy chain only) – Go to question 405
• IgA (heavy chain only) – Go to question 405
• IgM (heavy chain only) – Go to question 405
• IgD (heavy chain only) – Go to question 405
• IgE (heavy chain only) – Go to question 405
• Kappa (light chain only) – Go to question 405
• Lambda (light chain only) – Go to question 405
400. Specify Amyloidosis classification
• AL amyloidosis – Go to question 407
• AH amyloidosis – Go to question 407
• AHL amyloidosis – Go to question 407
401. Select monoclonal gammopathy of renal significance (MGRS) classification
• Light chain fanconi syndrome – Go to question 403
• Proximal tubulopathy without crystals – Go to question 403
• Crystal-storing histiocytosis – Go to question 403
• Non-amyloid fibrillary glomerulonephritis – Go to question 403
• Immunotactoid glomerulopathy (ITGN)/ Glomerulonephritis with organized monoclonal microtubular immunoglobulin deposits (GOMMID) – Go to question 403
• Type 1 cryoglobulinemic glomerulonephritis – Go to question 403
• Monoclonal immunoglobulin deposition disease (MIDD) – Go to question 402
• Proliferative glomerulonephritis with monoclonal immunoglobulin G deposits (PGNMID) – Go to question 403
• C3 glomerulopathy with monoclonal gammopathy – Go to question 403
• Unknown – Go to question 403
402. Select monoclonal immunoglobulin deposition disease (MIDD) subtype
• Light chain deposition disease (LCDD)
• Light and heavy chain deposition disease (LHCDD)
• Heavy chain deposition disease (HCDD)
403. Was documentation submitted to the CIBMTR? (e.g. pathology report)
• Yes – Go to question 407
• No – Go to question 407
404. Solitary plasmacytoma was
• Extramedullary – Go to question 407
• Bone derived – Go to question 407
405. 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 406
• Stage II (Fitting neither Stage I or Stage III) – Go to question 406
• 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 406
• Unknown – Go to question 407
406. 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)
407. Did the recipient have a preceding or concurrent plasma cell disorder?
• Yes – Go to question 408
• No – Go to question 411
408. Specify preceding / concurrent disorder
• Multiple myeloma– Go to question 410
• Multiple myeloma-light chain only – Go to question 410
• Multiple myeloma-non-secretory – Go to question 410
• Plasma cell leukemia – Go to question 410
• Solitary plasmacytoma (no evidence of myeloma) – Go to question 410
• Smoldering myeloma – Go to question 410
• Amyloidosis – Go to question 410
• Osteosclerotic myeloma / POEMS syndrome – Go to question 410
• Monoclonal gammopathy of unknown significance (MGUS) – Go to question 410
• Monoclonal gammopathy of renal significance (MGRS) – Go to question 410
• Other plasma cell disorder (PCD) – Go to question 409
409. Specify other preceding/concurrent disorder: ___________________________________
410. Date of diagnosis of preceding / concurrent disorder: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY MM DD
Copy questions 408- 410 to report more than one concurrent or preceding disorder.
411. Serum β2-microglobulin
• Known – Go to question 412
• Unknown – Go to question 413
412. Serum β2-microglobulin: ___ ___ ___ ● ___ ___ ___ μg/dL
mg/L
nmol/L
413. Serum albumin
• Known – Go to question 414
• Unknown – Go to question 415
414. Serum albumin: ___ ___ ● ___ g/dL
g/L
I.S.S. at diagnosis
415. Stage
• Known – Go to question 416
• Unknown – Go to question 417
416. Stage
• 1 (Serum β2-microglobulin < 3.5 mg/L, Serum albumin ≥ 3.5 g/dL)
• 2 (Not fitting stage 1 or 3)
• 3 (Serum β2-microglobulin ≥ 5.5 mg/L; Serum albumin —)
R - I.S.S. at diagnosis
417. Stage
• Known – Go to question 418
• Unknown – Go to question 419
418. Stage
• 1 (ISS stage I and no high-risk cytogenetic abnormalities by FISH and normal LDH levels)
• 2 (Not R-ISS stage I or III)
• 3 (ISS stage III and either high-risk cytogenetic abnormalities by FISH or high LDH levels)
419. Plasma cells in blood by flow cytometry
• Known – Go to question 420
• Unknown – Go to question 421
420. ___ ___• ___ ___ %
421. Plasma cells in blood by morphologic assessment
• Known – Go to question 422
• Unknown – Go to question 424
422. ___ ___%
423. ___ ___ ___ ___ ___ • ___ ___ □ x 109/L (x 103/mm3)
□ x 106/L
424. LDH
• Known – Go to question 425
• Unknown – Go to question 427
425. ___ ___ ___ ___ ___ ● ___ ___ U/L
μkat/L
426. Upper limit of normal for LDH: ___ ___ ___ ___ ___ • ___ ___
Labs at diagnosis
427. Were cytogenetics tested (karyotyping or FISH)? (at diagnosis)
• Yes – Go to question 428
• No – Go to question 440
• Unknown – Go to question 440
428. Were cytogenetics tested via FISH?
• Yes – Go to question 429
• No – Go to question 434
429. Results of tests
• Abnormalities identified – Go to question 430
• No abnormalities – Go to question 433
Specify cytogenetic abnormalities identified via FISH at diagnosis:
430. International System for Human Cytogenetic Nomenclature (ISCN) compatible string:____________________
431. 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– Go to question 432
432. Specify other abnormality:_______________________________
433. Was documentation submitted to the CIBMTR? (e.g. FISH report)
• Yes
• No
434. Were cytogenetics tested via karyotyping?
• Yes – Go to question 435
• No – Go to question 440
435. Results of tests
• Abnormalities identified – Go to question 436
• No evaluable metaphases – Go to question 439
• No abnormalities – Go to question 439
Specify cytogenetic abnormalities identified via conventional cytogenetics at diagnosis
436. International System for Human Cytogenetic Nomenclature (ISCN) compatible string:____________________
437. 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– Go to question 438
438. Specify other abnormality:________________________________
439. Was documentation submitted to the CIBMTR? (e.g. karyotyping report)
• Yes
• No
Status at transplantation / infusion
440. What is the hematologic disease status?
• Stringent complete response (sCR)
• Complete response (CR)
• Very good partial response (VGPR )
• Partial response (PR)
• No response (NR) / stable disease (SD)
• Progressive disease (PD)
• Relapse from CR (Rel) (untreated)
• Unknown
441. Date assessed: ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to signature line
YYYY MM DD
442. Specify amyloidosis hematologic response (for Amyloid patients only)
• Complete response (CR)
• Very good partial response (VGPR)
• Partial response (PR)
• No response (NR) / stable disease (SD)
• Progressive disease (PD)
• Relapse from CR (Rel) (untreated)
• Unknown
443. Date assessed: ___ ___ ___ ___ - ___ ___ - ___ ___ – Go to signature line
YYYY MM DD
Solid Tumors
444. 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) – Go to question 445
445. Specify other solid tumor: ________________________________- Go to signature line
Aplastic Anemia
446. Specify the aplastic anemia classification – If the recipient developed MDS or AML, indicate MDS or AML as the primary disease.
• Acquired AA, not otherwise specified (301) – Go to question 447
• Acquired AA secondary to chemotherapy (313) – Go to question 447
• Acquired AA secondary to hepatitis (302) (any form of hepatitis)– Go to question 447
• Acquired AA secondary to immunotherapy or immune effector cell therapy (314) – Go to question 447
• Acquired AA secondary to toxin / other drug (303) – Go to question 447
• Acquired amegakaryocytosis (not congenital) (304) – Go to Signature Line
• Acquired pure red cell aplasia (not congenital) (306) – Go to Signature Line
• Other acquired cytopenic syndrome (309) – Go to question 448
447. Specify severity
• Severe / very severe
• Not severe
448. Specify other acquired cytopenic syndrome: __________________________- Go to Signature Line
Inherited Bone Marrow Failure Syndromes
449. Specify the inherited bone marrow failure syndrome classification - If the recipient developed MDS or AML, indicate MDS or AML as the primary disease.
• Diamond-Blackfan anemia (pure red cell aplasia) (312) – Go to question 450
• Dyskeratosis congenita (307) – Go to signature line
• Fanconi anemia (311)– Go to question 450
• Severe congenital neutropenia (including Kostmann syndrome)(460) – Go to signature line
• Shwachman-Diamond (305) – Go to question 450
450. Did the recipient receive gene therapy to treat the inherited bone marrow failure syndrome?
• Yes - Also complete Cellular Therapy Product and Infusion forms 4003 and 4006.
• No
Hemoglobinopathies
451. Specify the hemoglobinopathy classification
• Sickle cell disease (356) – Go to question 454
• Transfusion dependent thalassemia (360) – Go to question 452
• Other hemoglobinopathy (359) – Go to question 453
452. Specify transfusion dependent thalassemia
• Transfusion dependent beta thalassemia (357) – Go to question 454
• Other transfusion dependent thalassemia (358) – Go to question 454
453. Specify other hemoglobinopathy:______
454. Did the recipient receive gene therapy to treat the hemoglobinopathy?
• Yes - Also complete Cellular Therapy Product and Infusion forms 4003 and 4006. If transfusion dependent thalassemia, go to question 455, else go to signature line
• No - If transfusion dependent thalassemia, go to question 455, else go to signature line
Questions 455-487 are for transfusion dependent thalassemia
455. Was tricuspid regurgitant jet velocity (TRJV) measured by echocardiography?
• Yes – Go to question 456
• No– Go to question 458
• Unknown - Go to question 458
456. TRJV measurement
• Known – Go to question 457
• Unknown– Go to question 458
457. TRJV measurement: __ __● ___ m/sec
458. Was liver iron content (LIC) tested within 6 months prior to infusion?
• Yes – Go to question 459
• No – Go to question 461
459. Liver iron content: ___ ___ ___ ● ___
• mg Fe/g liver dry weight
• g Fe/kg liver dry weight
• µmol Fe / g liver dry weight
460. Method used to estimate?
• T2*MRI
• SQUID MRI
• FerriScan
• Liver biopsy
• Other
461. Is the recipient red blood cell transfusion dependent? (requiring transfusion to maintain HGB 9-10 g/dL)
• Yes – Go to question 462
• No – Go to question 469
462. Year of first transfusion (since diagnosis): ___ ___ ___ ___
YYYY
463. Was iron chelation therapy given at any time since diagnosis?
• Yes – Go to question 464
• No – Go to question 469
• Unknown – Go to question 469
464. 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 – 467
• No, iron chelation therapy given, but does not meet criteria – Go to question 465
• Iron chelation therapy given, but details of administration unknown – Go to question 467
465. Specify reason criteria not met
• Non-adherence – Go to question 467
• Toxicity due to iron chelation therapy – Go to question 467
• Other – Go to question 466
466. Specify other reason criteria not met: ______________________
467. Year iron chelation therapy started
• Known – Go to question 468
• Unknown – Go to question 469
468. Year started: ___ ___ ___ ___
YYYY
469. Did the recipient have hepatomegaly? (> 2 cm below costal margin)
• Yes– Go to question 470
• No– Go to question 471
• Unknown– Go to question 471
470. Liver size as measured below the costal margin at most recent evaluation: ___ ___ ● ___ cm
471. Was a liver biopsy performed at any time since diagnosis?
• Yes – Go to questions 472
• No – Go to questions 479
472. Date assessed
• Known – Go to question 473
• Unknown – Go to question 474
473. Date assessed: ___ ___ ___ ___ — ___ ___ — ___ ___ □ Date estimated
YYYY MM DD
474. Was there evidence of liver cirrhosis?
• Yes
• No
• Unknown
475. Was there evidence of liver fibrosis?
• Yes – Go to question 476
• No – Go to question 477
• Unknown – Go to question 477
476. Type of fibrosis
• Bridging
• Peri portal
• Other
• Unknown
477. Was there evidence of chronic hepatitis?
• Yes
• No
• Unknown
478. Was documentation submitted to the CIBMTR? (e.g., liver biopsy)
• Yes
• No
479. Is there evidence of abnormal cardiac iron deposition based on MRI of the heart at time of infusion?
• Yes
• No
480. Did the recipient have a splenectomy?
• Yes
• No
• Unknown
Laboratory studies at last evaluation prior to start of preparative regimen
481. Serum iron
• Known – Go to questions 482
• Unknown – Go to questions 483
482. ___ ___ ___● ___ ___ µg / dL
µmol / L
483. Total iron binding capacity (TIBC)
• Known – Go to question 484
• Unknown – Go to question 485
484. ___ ___ ___ ● ___ ___ µg / dL
µmol / L
485. Total serum bilirubin
• Known – Go to question 486
• Unknown – Go to question Signature line
486. ___ ___ ___ ● ___ mg/dL
μmol/L
487. Upper limit of normal for your institution: ___ ___ ___ ● ___
Disorders of the Immune System
488. Specify disorder of immune system classification
• Adenosine deaminase (ADA) deficiency / severe combined immunodeficiency (SCID) (401) – Go to question 492
• Absence of T and B cells SCID (402) – Go to question 492
• Absence of T, normal B cell SCID (403) – Go to question 492
• Omenn syndrome (404) – Go to question 492
• Reticular dysgenesis (405) – Go to question 492
• Bare lymphocyte syndrome (406) – Go to question 492
• Other SCID (419) – Go to question 489
• SCID, not otherwise specified (410) – Go to question 492
• Ataxia telangiectasia (451) – Go to question 492
• HIV infection (452) – Go to question 492
• DiGeorge anomaly (454) – Go to question 492
• Common variable immunodeficiency (457) – Go to question 492
• Leukocyte adhesion deficiencies, including GP180, CD-18, LFA and WBC adhesion deficiencies (459) – Go to question 492
• Neutrophil actin deficiency (461) – Go to question 492
• Cartilage-hair hypoplasia (462) – Go to question 492
• CD40 ligand deficiency (464) – Go to question 492
• Other immunodeficiencies (479) – Go to question 490
• Immune deficiency, not otherwise specified (400) – Go to question 492
• Chediak-Higashi syndrome (456) – Also complete Pigmentary Dilution Disorder (PDD) Pre-HCT Data Form – Go to question 492
• Griscelli syndrome type 2 (465) – Also complete Pigmentary Dilution Disorder (PDD) Pre-HCT Data Form – Go to question 492
• Hermansky-Pudlak syndrome type 2 (466) – Also complete Pigmentary Dilution Disorder (PDD) Pre-HCT Data Form – Go to question 492
• Other pigmentary dilution disorder (469) – Also complete Pigmentary Dilution Disorder (PDD) Pre-HCT Data Form – Go to question 491
• Chronic granulomatous disease (455) – Go to question 492
• Wiskott-Aldrich syndrome (453) – Go to question 492
• X-linked lymphoproliferative syndrome (458) – Go to question 492
489. Specify other SCID: ____________________________ – Go to question 492
490. Specify other immunodeficiency: ____________________________– Go to question 492
491. Specify other pigmentary dilution disorder: ____________________________– Go to question 492
492. Did the recipient have an active or recent infection with a viral pathogen within 60 days of HCT?
• Yes– Go to question 493
• No– Go to question 494
493. Specify viral pathogen (check all that apply)
• 304 Adenovirus
• 341 BK Virus
• 344 Coronavirus
• 303 Cytomegalovirus (CMV)
• 347 Chikungunya 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)
• 320 Rotavirus (all species)
• 315 Rubella Virus
• 302 Varicella Virus
• 348 West Nile Virus (WNV)
494. Has the recipient ever been infected with PCP/PJP?
• Yes
• No
495. Does the recipient have GVHD due to maternal cell engraftment pre-HCT? (SCID only)
• Yes
• No
Inherited Abnormalities of Platelets
496. Specify inherited abnormalities of platelets classification
Congenital amegakaryocytosis / congenital thrombocytopenia (501)
Glanzmann thrombasthenia (502)
Other inherited platelet abnormality (509) – Go to question 497
497. Specify other inherited platelet abnormality: ________________________________- Go to signature line
Inherited Disorders of Metabolism
498. Specify inherited disorders of metabolism classification
• Osteopetrosis (malignant infantile osteopetrosis) (521)
Leukodystrophies
• Metachromatic leukodystrophy (MLD) (542)
• Adrenoleukodystrophy (ALD) (543) – Go to question 500
• Krabbe disease (globoid leukodystrophy) (544)
• Lesch-Nyhan (HGPRT deficiency) (522)
• Neuronal ceroid lipofuscinosis (Batten disease) (523)
Mucopolysaccharidoses
• Hurler syndrome (IH) (531)
• Scheie syndrome (IS) (532)
• Hunter syndrome (II) (533)
• Sanfilippo (III) (534)
• Morquio (IV) (535)
• Maroteaux-Lamy (VI) (536)
• β-glucuronidase deficiency (VII) (537)
• Mucopolysaccharidosis (V) (538)
• Mucopolysaccharidosis, not otherwise specified (530)
Mucolipidoses
• Gaucher disease (541)
• Niemann-Pick disease (545)
• I-cell disease (546)
• Wolman disease (547)
• Glucose storage disease (548)
• Mucolipidoses, not otherwise specified (540)
Polysaccharide hydrolase abnormalities
• Aspartyl glucosaminidase (561)
• Fucosidosis (562)
• Mannosidosis (563)
• Polysaccharide hydrolase abnormality, not otherwise specified (560)
• Other inherited metabolic disorder (529) – Go to question 499
• Inherited metabolic disorder, not otherwise specified (520)
499. Specify other inherited metabolic disorder: __________________________ - Go to signature line
500. Loes composite score: __ __ Adrenoleukodystrophy (ALD) only - Go to signature line
Histiocytic Disorders
501. Specify histiocytic disorder classification
Hemophagocytic lymphohistiocytosis (HLH) (571) – Go to question 503
Langerhans cell histiocytosis (histiocytosis-X) (572)
Hemophagocytosis (reactive or viral associated) (573)
Malignant histiocytosis (574)
Other histiocytic disorder (579) – Go to question 502
Histiocytic disorder, not otherwise specified (570)
502. Specify other histiocytic disorder: ____________________________________- Go to signature line
503. Did the recipient have an active or recent infection with a viral pathogen within 60 days of HCT? Hemophagocytic lymphohistiocytosis (HLH) only
• Yes– Go to question 504
• No– Go to question 505
504. 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)
• 320 Rotavirus (all species)
• 315 Rubella Virus
• 302 Varicella Virus
• 348 West Nile Virus (WNV)
505. Has the recipient ever been infected with PCP/PJP
• Yes- Go to signature line
• No- Go to signature line
Autoimmune Diseases
506. 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 507
Bowel diseases
• Crohn’s disease (649)
• Ulcerative colitis (650)
• Other autoimmune bowel disorder (651) – Go to question 508
Metabolic
• Diabetes mellitus type 1 (660)
Other
• Other autoimmune disease (629) – Go to question 509
507. Specify other autoimmune cytopenia:_________________________________
508. Specify other autoimmune bowel disorder:_________________________________
509. Specify other autoimmune disease: ____________________
- Go to signature line
Tolerance Induction Associated with Solid Organ Transplant
510. Specify solid organ transplanted (check all that apply)
• Kidney
• Liver
• Pancreas
• Other organ - Go to question 511
511. Specify other organ: ______________________ - Go to signature line
Other Disease
512. Specify other disease: _________________________________________- Go to signature line
First Name: ____________________________________________________________________________
Last Name:
E-mail address:
Date: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY MM DD