Download:
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pdfDisease Classification
CIBMTR Use Only
Sequence Number:
Date Received:
OMB No: 0915-0310
Expiration Date: 10/31/2022
Public Burden Statement: The purpose of the data collection is to fulfill the legislative
mandate to establish and maintain a standardized database of allogeneic marrow
and cord blood transplants performed in the United States or using a donor from the
United States. The data collected also meets the C.W. Bill Young Cell Transplantation
Program requirements to provide relevant scientific information not containing
individually identifiable information available to the public in the form of summaries
and data sets. An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a currently valid OMB control
number. The OMB control number for this information collection is 0915-0310 and it
is valid until 10/31/2022. This information collection is voluntary under The Stem Cell
Therapeutic and Research Act of 2005, Public Law (Pub. L.) 109–129, as amended
by the Stem Cell Therapeutic and Research Reauthorization Act of 2010, Public Law
111–264 (the Act) and the Stem Cell Therapeutic and Research Reauthorization Act
of 2015, Public Law 114-104. Public reporting burden for this collection of information
is estimated to average 0.43 hours per response, including the time for reviewing
instructions, searching existing data sources, and completing and reviewing the
collection of information. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden,
to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville,
Maryland, 20857 or [email protected].
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Event date: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
CIBMTR Form 2402 revision 5 (page 1 of 71). Form released May, 2020. Last Updated July, 2020.
Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Primary Disease for HCT / Cellular Therapy
1. Date of diagnosis of primary disease for HCT / cellular therapy: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
2. What was the primary disease for which the HCT / cellular therapy was performed?
☐ Acute myelogenous leukemia (AML or ANLL) (10) - Go to question 3
☐ Acute lymphoblastic leukemia (ALL) (20) - Go to question 96
☐ Acute leukemia of ambiguous lineage and other myeloid neoplasms (80) - Go to question 164
☐ Chronic myelogenous leukemia (CML) (40) - Go to question 168
☐ Myelodysplastic 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 260
☐ Other leukemia (30) (includes CLL) - Go to question 373
☐ Hodgkin lymphoma (150) - Go to question 380
☐ Non-Hodgkin lymphoma (100) - Go to question 380
☐ Multiple myeloma / plasma cell disorder (PCD) (170) - Go to question 398
☐ Solid tumors (200) - Go to question 446
☐ Severe aplastic anemia (300) (If the recipient developed MDS or AML, indicate MDS or AML as the primary disease)
- Go to question 448
☐ Inherited abnormalities of erythrocyte differentiation or function (310) - Go to question 450
☐ Disorders of the immune system (400) - Go to question 484
☐ Inherited abnormalities of platelets (500) - Go to question 492
☐ Inherited disorders of metabolism (520) - Go to question 494
☐ Histiocytic disorders (570) - Go to question 497
☐ Autoimmune diseases (600) - Go to question 502
☐ Tolerance induction associated with solid organ transplant (910) - Go to question 506
☐ Recessive dystrophic epidermolysis bullosa (920) - Go to First Name
☐ Other disease (900) - Go to question 508
CIBMTR Form 2402 revision 5 (page 2 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Acute Myelogenous Leukemia (AML)
3. Specify the AML classification
AML with recurrent genetic abnormalities
☐ AML with t(9;11) (p22.3;q23.3); MLLT3-KMT2A (5)
☐ AML with t(6;9) (p23;q34.1); DEK-NUP214 (6)
☐ AML with inv(3) (q21.3;q26.2) or t(3;3) (q21.3;q26.2); GATA2, MECOM (7)
☐ AML (megakaryoblastic) with t(1;22) (p13.3;q13.3); RBM15-MKL1 (8)
☐ AML with t(8;21); (q22; q22.1); RUNX1-RUNX1T1 (281)
☐ AML with inv(16) (p13.1;1q22) or t(16;16)(p13.1; q22); CBFB-MYH11 (282)
☐ APL with PML-RARA (283)
☐ AML with BCR-ABL1 (provisional entity) (3)
☐ AML with mutated NPM1 (4)
☐ AML with biallelic mutations of CEBPA (297)
☐ AML with mutated RUNX1 (provisional entity) (298)
☐ AML with 11q23 (MLL) abnormalities (i.e., t(4;11), t(6;11), t(9;11), t(11;19)) (284)
☐ AML with myelodysplasia – related changes (285)
☐ Therapy related AML (t-AML) (9)
AML, not otherwise specified
☐ 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?
5. Is the disease (AML) therapy related?
☐ Yes – Also complete MDS or MPN Disease Classification questions ☐ No
☐ Yes ☐ No ☐ Unknown
6. Did the recipient have a predisposing condition?
☐ Yes
7. Specify condition
☐ No
☐ Bloom syndrome
☐ Unknown
☐ Down syndrome
☐ Fanconi anemia – Also complete CIBMTR Form 2029
☐ Dyskeratosis congenita
☐ Other condition
8.
Specify other condition:____________________________________
CIBMTR Form 2402 revision 5 (page 3 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Labs at diagnosis
9. Were cytogenetics tested (karyotyping or FISH)? (at diagnosis)
☐ Yes
☐ No
☐ Unknown
10. Were cytogenetics tested via FISH?
☐ Yes
☐ No
11. Results of tests
☐ Abnormalities identified
☐ No abnormalities
Specify cytogenetic abnormalities identified at diagnosis
12. 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–
CIBMTR Form 2402 revision 5 (page 4 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ del(17q) / 17q–
☐ del(20q) / 20q–
☐ del(21q) / 21q–
☐ inv(3)
☐ inv(16)
☐ (11q23) any abnormality
☐ 12p any abnormality
☐ Other abnormality
15. Specify other abnormality:
________________________
16. Were cytogenetics tested via karyotyping?
☐ Yes
☐ No
17. Results of tests
☐ Abnormalities identified
☐ No evaluable metaphases
☐ No abnormalities
Specify cytogenetic abnormalities identified at diagnosis
18. 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
CIBMTR Form 2402 revision 5 (page 5 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ +22
☐ t(3;3)
☐ t(6;9)
☐ t(8;21)
☐ t(9;11)
☐ t(9;22)
☐ t(15;17) and variants
☐ t(16;16)
☐ del(3q) / 3q–
☐ del(5q) / 5q–
☐ del(7q) / 7q–
☐ del(9q) / 9q–
☐ del(11q) / 11q–
☐ del(16q) / 16q–
☐ del(17q) / 17q–
☐ del(20q) / 20q–
☐ del(21q) / 21q–
☐ inv(3)
☐ inv(16)
☐ (11q23) any abnormality
☐ 12p any abnormality
☐ Other abnormality
21. Specify other abnormality:
_________________________________
22. Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)
☐ Yes
☐ No
23. Were tests for molecular markers performed? (e.g. PCR, NGS) (at diagnosis)
☐ Yes
☐ No
☐ Unknown
Specify molecular markers identified at diagnosis
24. CEBPA
☐ Positive
☐ Negative
☐ Not done
25. Specify CEBPA mutation
☐ Biallelic (homozygous)
☐ Monoallelic (heterozygous)
☐ Unknown
26. FLT – TKD (point mutations in D835 or deletions of codon I836)
☐ Positive ☐ Negative
☐ Not done
27. FLT3 – ITD mutation
☐ Positive
☐ Negative
☐ Not done
28. FLT3 – ITD allelic ratio
☐ Known
☐ Unknown
29. Specify FLT3 - ITD allelic ratio: ___ • ___
CIBMTR Form 2402 revision 5 (page 6 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ Positive
☐ Positive
☐ Positive
☐ Positive
30. IDH1
31. IDH2
32. KIT
33. NPM1
☐ Negative
☐ Negative
☐ Negative
☐ Negative
☐ Not done
☐ Not done
☐ Not done
☐ Not done
34. Other molecular marker
☐ Positive
35. Specify other molecular marker:_____________________________
☐ Negative
☐ Not done
Copy and complete questions 34 - 35 for multiple molecular markers.
Labs between diagnosis and last evaluation
36. Were cytogenetics tested (karyotyping or FISH)? (between diagnosis and last evaluation)
☐ Yes
☐ No
☐ Unknown
37. Were cytogenetics tested via FISH?
☐ Yes
☐ No
38. Results of tests
☐ Abnormalities identified
☐ No abnormalities
Specify cytogenetic abnormalities identified between diagnosis
and last evaluation
39. 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)
CIBMTR Form 2402 revision 5 (page 7 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ t(6;9)
☐ t(8;21)
☐ t(9;11)
☐ t(9;22)
☐ t(15;17) and variants
☐ t(16;16)
☐ del(3q) / 3q–
☐ del(5q) / 5q–
☐ del(7q) / 7q–
☐ del(9q) / 9q–
☐ del(11q) / 11q–
☐ del(16q) / 16q–
☐ del(17q) / 17q–
☐ del(20q) / 20q–
☐ del(21q) / 21q–
☐ inv(3)
☐ inv(16)
☐ (11q23) any abnormality
☐ 12p any abnormality
☐ Other abnormality
42. Specify other abnormality:
_________________________________
CIBMTR Form 2402 revision 5 (page 8 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
43. Were cytogenetics tested via karyotyping?
☐ Yes
☐ No
44. Results of tests
☐ Abnormalities identified
☐ No evaluable metaphases
☐ No abnormalities
Specify cytogenetic abnormalities identified between diagnosis
and last evaluation
45. International System for Human Cytogenetic Nomenclature
(ISCN) compatible string:_________________________________
46. Specify number of distinct cytogenetic abnormalities
☐ 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–
CIBMTR Form 2402 revision 5 (page 9 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ del(20q) / 20q–
☐ del(21q) / 21q–
☐ inv(3)
☐ inv(16)
☐ (11q23) any abnormality
☐ 12p any abnormality
☐ Other abnormality
48. Specify other abnormality:
_________________________________
49. Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)
☐ Yes
☐ No
50. Were tests for molecular markers performed? (e.g. PCR, NGS) (between diagnosis and last evaluation)
☐ Yes
☐ No
☐ Unknown
Specify molecular markers identified between diagnosis
51. CEBPA
☐ Positive
☐ Negative
☐ Not done
52. Specify CEBPA mutation
☐ Biallelic (homozygous)
☐ Monoallelic (heterozygous)
☐ Unknown
53. FLT3 – TKD (point mutations in D835 or deletions of codon I836)
☐ Positive ☐ Negative
☐ Not done
54. FLT3 – ITD mutation
☐ Positive
☐ Negative
☐ Not done
57. IDH1
58. IDH2
59. KIT
60. NPM1
55. FLT3 – ITD allelic ratio
☐ Known
☐ Unknown
56. Specify FLT3 - ITD allelic ratio: ___ • ___
☐ Positive
☐ Positive
☐ Positive
☐ Positive
☐ Negative
☐ Negative
☐ Negative
☐ Negative
☐ Not done
☐ Not done
☐ Not done
☐ Not done
61. Other molecular marker
☐ Positive
62. Specify other molecular marker:_____________________________
☐ Negative
☐ Not done
Copy and complete questions 61-62 to report multiple other molecular markers.
CIBMTR Form 2402 revision 5 (page 10 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Labs at last evaluation
63. Were cytogenetics tested (karyotyping or FISH)? (at last evaluation)
☐ Yes
☐ No
☐ Unknown
64. Were cytogenetics tested via FISH?
☐ Yes
☐ No
65. Results of tests
☐ Abnormalities identified
☐ No abnormalities
Specify cytogenetic abnormalities identified at last evaluation
66. International System for Human Cytogenetic Nomenclature
(ISCN) compatible string:_________________________________
67. Specify number of distinct cytogenetic abnormalities
☐ One (1)
☐ Two (2)
☐ Three (3)
☐ Four or more (4 or more)
68. Specify abnormalities (check all that apply)
☐ -5
☐ -7
☐ -17
☐ -18
☐ -X
☐ -Y
☐ +4
☐ +8
☐ +11
☐ +13
☐ +14
☐ +21
☐ +22
☐ t(3;3)
☐ t(6;9)
☐ t(8;21)
☐ t(9;11)
☐ t(9;22)
☐ t(15;17) and variants
☐ t(16;16)
☐ del(3q) / 3q–
☐ del(5q) / 5q–
☐ del(7q) / 7q–
☐ del(9q) / 9q–
☐ del(11q) / 11q–
☐ del(16q) / 16q–
CIBMTR Form 2402 revision 5 (page 11 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ del(17q) / 17q–
☐ del(20q) / 20q–
☐ del(21q) / 21q–
☐ inv(3)
☐ inv(16)
☐ (11q23) any abnormality
☐ 12p any abnormality
☐ Other abnormality
69. Specify other abnormality:
_________________________________
70. Were cytogenetics tested via karyotyping?
☐ Yes
☐ No
71. Results of tests
☐ Abnormalities identified
☐ No evaluable metaphases
☐ No abnormalities
Specify cytogenetic abnormalities identified at last evaluation
72. International System for Human Cytogenetic Nomenclature
(ISCN) compatible string:_________________________________
73. Specify number of distinct cytogenetic abnormalities
☐ One (1)
☐ Two (2)
☐ Three (3)
☐ Four or more (4 or more)
74. Specify abnormalities (check all that apply)
☐ -5
☐ -7
☐ -17
☐ -18
☐ -X
☐ -Y
☐ +4
☐ +8
☐ +11
☐ +13
☐ +14
☐ +21
☐ +22
CIBMTR Form 2402 revision 5 (page 12 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ t(3;3)
☐ t(6;9)
☐ t(8;21)
☐ t(9;11)
☐ t(9;22)
☐ t(15;17) and variants
☐ t(16;16)
☐ del(3q) / 3q–
☐ del(5q) / 5q–
☐ del(7q) / 7q–
☐ del(9q) / 9q–
☐ del(11q) / 11q–
☐ del(16q) / 16q–
☐ del(17q) / 17q–
☐ del(20q) / 20q–
☐ del(21q) / 21q–
☐ inv(3)
☐ inv(16)
☐ (11q23) any abnormality
☐ 12p any abnormality
☐ Other abnormality
75. Specify other abnormality:
_________________________________
76. Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)
☐ Yes
☐ No
77. Were tests for molecular markers performed? (e.g. PCR, NGS) (at last evaluation)
☐ Yes
☐ No
☐ Unknown
Specify molecular markers identified at last evaluation
78. CEBPA
☐ Positive
☐ Negative
☐ Not done
79. Specify CEBPA mutation
☐ Biallelic (homozygous)
☐ Monoallelic (heterozygous)
☐ Unknown
80. FLT3 – TKD (point mutations in D835 or deletions of codon I836)
☐ Positive ☐ Negative
☐ Not done
81. FLT3 – ITD mutation
☐ Positive
☐ Negative
☐ Not done
82. FLT3 – ITD allelic ratio
☐ Known
☐ Unknown
83. Specify FLT3 - ITD allelic ratio: ___ • ___
CIBMTR Form 2402 revision 5 (page 13 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ Positive
☐ Positive
☐ Positive
☐ Positive
84. IDH1
85. IDH2
86. KIT
87. NPM1
☐ Negative
☐ Negative
☐ Negative
☐ Negative
☐ Not done
☐ Not done
☐ Not done
☐ Not done
88. Other molecular marker
☐ Positive
89. Specify other molecular marker:_____________________________
☐ Negative
☐ Not done
Copy and complete questions 88-89 to report multiple other molecular markers.
CNS Leukemia
90. Did the recipient have central nervous system leukemia at any time prior to the start of the preparative regimen / infusion?
☐ Yes
☐ No
☐ Unknown
Status at transplantation / 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
92. How many cycles of induction therapy were required to achieve
1st complete remission? (includes CRi)
☐ 1 ☐ 2 ☐ ≥ 3
93. Was the recipient in remission by flow cytometry?
☐ Yes
☐ 1st relapse - Go to question 94
☐ 2nd relapse - Go to question 94
☐ ≥ 3rd relapse - Go to question 94
☐ No treatment - Go to question 95
☐ No ☐ Unknown
☐ Not applicable
- Go to question 95
94. Date of most recent relapse:__ __ __ __ / __ __ / __ __
YYYY
MM
DD
95. Date assessed: __ __ __ __ / __ __ / __ __ - Go to signature line
YYYY
MM
DD
CIBMTR Form 2402 revision 5 (page 14 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Acute Lymphoblastic Leukemia (ALL)
96. Specify ALL classification
B-lymphoblastic leukemia / lymphoma
☐ B-lymphoblastic leukemia / lymphoma, NOS (B-cell ALL, NOS) (191)
☐ B-lymphoblastic leukemia / lymphoma with t(9;22)(q34.1;q11.2); BCR-ABL1 (192)
☐ B-lymphoblastic leukemia / lymphoma with t(v;11q23.3); KMT2A rearranged (193)
☐ B-lymphoblastic leukemia / lymphoma with t(1;19)(q23;p13.3); TCF3-PBX1 (194)
☐ B-lymphoblastic leukemia / lymphoma with t(12;21) (p13.2;q22.1); ETV6-RUNX1 (195)
☐ B-lymphoblastic leukemia / lymphoma with t(5;14) (q31.1;q32.3); IL3-IGH (81)
☐ B-lymphoblastic leukemia / lymphoma with Hyperdiploidy (51-65 chromosomes) (82)
☐ B-lymphoblastic leukemia / lymphoma with Hypodiploidy (<46 chromosomes) (83)
☐ B-lymphoblastic leukemia / lymphoma, BCR-ABL1-like (provisional entity) (94)
☐ B-lymphoblastic leukemia / lymphoma, with iAMP21 (95)
T-cell lymphoblastic leukemia / lymphoma
NK cell lympoblastic leukemia/lymphoma
☐ T-cell lymphoblastic leukemia/lymphoma (Precursor T-cell ALL) (196)
☐ Early T-cell precursor lymphoblastic leukemia (96)
☐ Natural killer (NK) - cell lymphoblastic leukemia / lymphoma (97)
97. Did the recipient have a predisposing condition?
☐ Yes
☐ No
☐ Unknown
98. Specify condition
☐ Aplastic anemia – Also complete CIBMTR Form 2028 — APL
☐ Bloom syndrome
☐ Down syndrome
☐ Fanconi anemia – Also complete CIBMTR Form 2029 — FAN
☐ Other condition
99. Specify other condition:____________________________________
100. Were tyrosine kinase inhibitors given for therapy at any time prior to start of the preparative regimen / infusion?
(e.g. imatinib mesylate, dasatinib, etc.)
☐ Yes
CIBMTR Form 2402 revision 5 (page 15 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
☐ No
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Laboratory studies at diagnosis
101. Were cytogenetics tested (karyotyping or FISH)? (at diagnosis)
☐ Yes
☐ No
☐ Unknown
102. Were cytogenetics tested via FISH? (at diagnosis)
☐ Yes
☐ No
103. Results of tests (at diagnosis)
☐ Abnormalities identified
☐ No abnormalities
Specify cytogenetic abnormalities identified 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
107. Specify other
abnormality:
______________
CIBMTR Form 2402 revision 5 (page 16 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
108. Were cytogenetics tested via karyotyping? (at diagnosis)
☐ Yes
☐ No
109. Results of tests (at diagnosis)
☐ Abnormalities identified
☐ No evaluable metaphases
☐ No abnormalities
Specify cytogenetic abnormalities identified 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
114. Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)
113. Specify other
abnormality:
______________
☐ Yes
CIBMTR Form 2402 revision 5 (page 17 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
☐ No
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
115. Were tests for molecular markers performed? (e.g. PCR, NGS) (at diagnosis)
☐ Yes
☐ No
☐ Unknown
Specify molecular markers identified at diagnosis
☐ Positive ☐ Negative
☐ Positive ☐ Negative
116. BCR / ABL
117. TEL-AML / AML1
☐ Not done
☐ Not done
118. Other molecular marker
☐ Positive
119. Specify other molecular marker:_____________________________
☐ Negative
☐ Not done
Copy and complete questions 118 - 119 for additional molecular markers
Laboratory studies between diagnosis and last evaluation
120. Were cytogenetics tested (karyotyping or FISH)? (between diagnosis and last evaluation)
☐ Yes
☐ No
☐ Unknown
121. Were cytogenetics tested via FISH? (between diagnosis and the last evaluation)
☐ Yes
☐ No
122. Results of tests (between diagnosis and the last evaluation)
☐ Abnormalities identified
☐ No abnormalities
Specify cytogenetic abnormalities identified 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)
CIBMTR Form 2402 revision 5 (page 18 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ del(6q) / 6q–
☐ del(9p) / 9p–
☐ del(12p) / 12p–
☐ add(14q)
☐ (11q23) any abnormality
☐ 9p any abnormality
☐ 12p any abnormality
☐ Hyperdiploid (> 50)
☐ Hypodiploid (< 46)
☐ iAMP21
☐ Other abnormality
126. Specify other
abnormality:
______________
127. Were cytogenetics tested via karyotyping? (between diagnosis and the last evaluation)
☐ Yes
☐ No
128. Results of tests (between diagnosis and the last evaluation)
☐ Abnormalities identified
☐ No evaluable metaphases
☐ No abnormalities
Specify cytogenetic abnormalities identified 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)
CIBMTR Form 2402 revision 5 (page 19 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ t(10;14)
☐ t(11;14)
☐ t(12;21)
☐ del(6q) / 6q–
☐ del(9p) / 9p–
☐ del(12p) / 12p–
☐ add(14q)
☐ (11q23) any abnormality
☐ 9p any abnormality
☐ 12p any abnormality
☐ Hyperdiploid (> 50)
☐ Hypodiploid (< 46)
☐ iAMP21
☐ Other abnormality
132. Specify other abnormality:
_________________________________
133. Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)
☐ Yes
☐ No
134. Were tests for molecular markers performed? (e.g. PCR, NGS) (between diagnosis and last evaluation)
☐ Yes
☐ No
☐ Unknown
Specify molecular markers identified between diagnosis and last evaluation
135. BCR / ABL
136. TEL-AML / AML1
☐ Positive ☐ Negative
☐ Positive ☐ Negative
☐ Not done
☐ Not done
137. Other molecular marker
☐ Positive
138. Specify other molecular marker:_____________________________
☐ Negative
☐ Not done
Copy and complete questions 137 - 138 for additional molecular markers
CIBMTR Form 2402 revision 5 (page 20 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Laboratory studies at last evaluation
139. Were cytogenetics tested (karyotyping or FISH)? (at last evaluation)
☐ Yes
☐ No
☐ Unknown
140. Were cytogenetics tested via FISH?
☐ Yes
☐ No
141. Results of tests
☐ Abnormalities identified
☐ No abnormalities
Specify cytogenetic abnormalities identified at last evaluation
142. International System for Human Cytogenetic Nomenclature
(ISCN) compatible string:_________________________________
143. Specify number of distinct cytogenetic abnormalities
☐ One (1)
☐ Two (2)
☐ Three (3)
☐ Four or more (4 or more)
144. Specify abnormalities (check all that apply)
☐ -7
☐ +4
☐ +8
☐ +17
☐ +21
☐ t(1;19)
☐ t(2;8)
☐ t(4;11)
☐ t(5;14)
☐ t(8;14)
☐ t(8;22)
☐ t(9;22)
☐ t(10;14)
☐ t(11;14)
☐ t(12;21)
☐ del(6q) / 6q–
☐ del(9p) / 9p–
☐ del(12p) / 12p–
☐ add(14q)
☐ (11q23) any abnormality
☐ 9p any abnormality
☐ 12p any abnormality
☐ Hyperdiploid (> 50)
☐ Hypodiploid (< 46)
☐ iAMP21
☐ Other abnormality
145. Specify other
abnormality:
______________
CIBMTR Form 2402 revision 5 (page 21 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
146. Were cytogenetics tested via karyotyping? (at last evaluation)
☐ Yes
☐ No
147. Results of tests
☐ Abnormalities identified
☐ No evaluable metaphases
☐ No abnormalities
Specify cytogenetic abnormalities identified at last evaluation
148. International System for Human Cytogenetic Nomenclature
(ISCN) compatible string:_________________________________
149. Specify number of distinct cytogenetic abnormalities
☐ One (1)
☐ Two (2)
☐ Three (3)
☐ Four or more (4 or more)
150. Specify abnormalities (check all that apply)
☐ -7
☐ +4
☐ +8
☐ +17
☐ +21
☐ t(1;19)
☐ t(2;8)
☐ t(4;11)
☐ t(5;14)
☐ t(8;14)
☐ t(8;22)
☐ t(9;22)
☐ t(10;14)
☐ t(11;14)
☐ t(12;21)
☐ del(6q) / 6q–
☐ del(9p) / 9p–
☐ del(12p) / 12p–
☐ add(14q)
☐ (11q23) any abnormality
☐ 9p any abnormality
☐ 12p any abnormality
☐ Hyperdiploid (> 50)
☐ Hypodiploid (< 46)
☐ iAMP21
☐ Other abnormality
152. Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)
151. Specify other
abnormality:
______________
☐ Yes
CIBMTR Form 2402 revision 5 (page 22 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
☐ No
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
153. Were tests for molecular markers performed? (e.g. PCR, NGS) (at last evaluation)
☐ Yes
☐ No
☐ Unknown
Specify molecular markers identified at last evaluation
☐ Positive ☐ Negative
☐ Positive ☐ Negative
154. BCR / ABL
155. TEL-AML / AML1
☐ Not done
☐ Not done
156. Other molecular marker
☐ Positive
157. Specify other molecular marker:_____________________________
☐ Negative
☐ Not done
Copy and complete questions 156 - 157 for additional molecular markers
CNS Leukemia
158. Did the recipient have central nervous system leukemia at any time prior to the start of the preparative regimen / infusion?
☐ Yes
☐ No
☐ Unknown
Status at transplantation / 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
160. How many cycles of induction therapy were required to achieve
1st complete remission? (includes CRi)
☐ 1 ☐ 2 ☐ ≥ 3
161. Was the recipient in remission by flow cytometry?
☐ Yes
☐ 1st relapse - Go to question 162
☐ 2nd relapse - Go to question 162
☐ ≥ 3rd relapse - Go to question 162
☐ No treatment - Go to question 163
☐ No ☐ Unknown
☐ Not applicable
- Go to question 163
162. Date of most recent relapse:__ __ __ __ / __ __ / __ __
YYYY
MM
DD
163. Date assessed: __ __ __ __ / __ __ / __ __ - Go to signature line
YYYY
MM
DD
CIBMTR Form 2402 revision 5 (page 23 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Acute Leukemias of Ambiguous Lineage and Other Myeloid Neoplasms
164. Specify acute leukemias of ambiguous lineage and other myeloid neoplasm classification
☐ Blastic plasmacytoid dendritic cell neoplasm (296)
☐ Acute undifferentiated leukemia (31)
☐ Mixed phenotype acute leukemia (MPAL) with t(9;22)(q34.1;q11.2); BCR-ABL1 (84)
☐ Mixed phenotype acute leukemia with t(v; 11q23.3); KMT2A rearranged (85)
☐ Mixed phenotype acute leukemia, B/myeloid, NOS (86)
☐ Mixed phenotype acute leukemia, T/myeloid, NOS (87)
☐ Other acute leukemia of ambiguous lineage or myeloid neoplasm (88)
165. Specify other acute leukemia of ambiguous lineage or myeloid neoplasm:
____________________________________________________________________________
Status at transplantation
166. What was the disease status? (based on hematological test results)
☐ Primary induction failure
☐ 1st complete remission (no previous bone marrow or extramedullary relapse)
☐ 2nd complete remission
☐ ≥ 3rd complete remission
☐ 1st relapse
☐ 2nd relapse
☐ ≥ 3rd relapse
☐ No treatment
167. Date assessed: __ __ __ __ / __ __ / __ __ - Go to signature line
YYYY
MM
DD
CIBMTR Form 2402 revision 5 (page 24 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Chronic Myelogenous Leukemia (CML)
168. Was therapy given prior to this HCT?
☐ Yes
☐ No
☐ Yes
☐ Yes
☐ Yes
☐ Yes
169. Combination chemotherapy
170. Hydroxyurea (Droxia, Hydrea)
171. Tyrosine kinase inhibitor (e.g.imatinib mesylate, dasatinib, nilotinib)
172.
Interferon-α (Intron, Roferon) (includes PEG)
173. Other therapy
☐ No
☐ No
☐ No
☐ No
☐ Yes
174. Specify other therapy:________________________________________________________
☐ No
175. What was the disease status?
☐ Complete hematologic response (CHR) preceded only by
chronic phase
☐ Complete hematologic response (CHR) preceded by
accelerated phase and/or blast phase
☐ Chronic phase
☐ Accelerated phase - Go to question 177
☐ Blast phase - Go to question 177
176. Specify level of response
177. Number
☐ No cytogenetic response (No CyR)
☐ Minimal cytogenetic response
☐ Minor cytogenetic response
☐ Partial cytogenetic response (PCyR)
☐ Complete cytogenetic response (CCyR)
☐ Major molecular remission (MMR)
☐ Complete molecular remission (CMR)
☐ 1st
☐ 2nd
☐ 3rd or higher
178. Date assessed: __ __ __ __ / __ __ / __ __ - Go to signature line
YYYY
MM
DD
CIBMTR Form 2402 revision 5 (page 25 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
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 377
☐ 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)
182. Was the disease MDS therapy related?
☐ Yes
☐ Yes
☐ No
☐ No
☐ Unknown
183. Did the recipient have a predisposing condition?
☐ Yes
184. Specify condition
☐ No
☐ Aplastic anemia
☐ Unknown
☐ DDX41-associated familial MDS
☐ Diamond-Blackfan Anemia
☐ Fanconi anemia
☐ GATA2 deficiency (including Emberger syndrome, MonoMac syndrome, DCML deficiency)
☐ Li-Fraumeni Syndrome
☐ Paroxysmal nocturnal hemoglobinuria
☐ RUNX1 deficiency (previously “familial platelet disorder with propensity to myeloid malignancies”)
☐ SAMD9- or SAMD9L-associated familial MDS
☐ Shwachman-Diamond Syndrome
☐ Telomere biology disorder (including dyskeratosis congenita)
☐ Other condition
185. Specify other condition:____________________________________
CIBMTR Form 2402 revision 5 (page 26 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Laboratory Studies at Diagnosis of MDS
186. Date CBC drawn:___ ___ ___ ___/ ___ ___ / ___ ___
YYYY
MM
DD
187. WBC
☐ Known
☐ Unknown
188. ___ ___ ___ ___ ___ ___ • ___
☐ x 10 /L (x 10 /mm )
9
3
3
☐ x 10 /L
6
189. Neutrophils
☐ Known
☐ Unknown
190. ___ ___%
191. Blasts in blood
☐ Known
☐ Unknown
192. ___ ___ ___ %
193. Hemoglobin
☐ Known
☐ Unknown
194. ___ ___ ___ ___ • ___ ___
☐ g/dL
☐ g/L
☐ mmol/L
195. Were RBCs transfused ≤ 30 days before date of test?
☐ Yes
☐ No
☐ Yes
☐ No
196. Platelets
☐ Known
☐ Unknown
197. ___ ___ ___ ___ ___ ___ ___
☐ x 10 /L (x 10 /mm )
9
3
3
198. Were platelets transfused ≤ 7 days before date of test?
☐ x 10 /L
6
199. Blasts in bone marrow
☐ Known
☐ Unknown
200. ___ ___ ___ %
201. Were cytogenetics tested (karyotyping or FISH)?
☐ Yes
☐ No
☐ Unknown
202. Were cytogenetics tested via FISH?
☐ Yes
☐ No
☐ Blood ☐ Bone Marrow
203. Sample source
204. Results of tests
☐ Abnormalities identified
☐ No abnormalities
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)
CIBMTR Form 2402 revision 5 (page 27 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
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
208. Specify other abnormality:____________
209. Was documentation submitted to the CIBMTR? (e.g. FISH report)
☐ Yes
☐ No
CIBMTR Form 2402 revision 5 (page 28 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
210. Were cytogenetics tested via karyotyping?
☐ Yes
☐ No
☐ Blood ☐ Bone Marrow
211. Sample source
212. Results of tests
☐ Abnormalities identified
☐ No evaluable metaphases
☐ No abnormalities
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-
CIBMTR Form 2402 revision 5 (page 29 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ del(12p) / 12p-
☐ del(13q) / 13q-
☐ del(20q) / 20q-
Inversion
☐ inv(3)
Other
☐ i17q
☐ Other abnormality
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
☐ No
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
☐ MDS-U with single lineage dysplasia and pancytopenia
☐ MDS-U based on defining cytogenetic abnormality
CIBMTR Form 2402 revision 5 (page 30 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
221. Specify the date of the most recent transformation:
___ ___ ___ ___/ ___ ___ / ___ ___ - Go to question 223
YYYY
MM
DD
222. Date of MDS diagnosis:
___ ___ ___ ___/ ___ ___ / ___ ___ - Go to signature line
YYYY
MM
DD
Laboratory studies at last evaluation prior to the start of the preparative regimen / infusion
223. Date CBC drawn:___ ___ ___ ___/ ___ ___ / ___ ___
YYYY
MM
DD
224. WBC
☐ Known
☐ Unknown
225. ___ ___ ___ ___ ___ ___ • ___
☐ x 10 /L (x 10 /mm )
9
3
3
☐ x 10 /L
6
226. Neutrophils
☐ Known
☐ Unknown
227. ___ ___%
228. Blasts in blood
☐ Known
☐ Unknown
229. ___ ___ ___ %
230. Hemoglobin
☐ Known
☐ Unknown
231. ___ ___ ___ ___ • ___ ___
☐ g/dL
☐ g/L
☐ mmol/L
232. Were RBCs transfused ≤ 30 days before date of test?
☐ Yes
☐ No
☐ Yes
☐ No
233. Platelets
☐ Known
☐ Unknown
234. ___ ___ ___ ___ ___ ___ ___
☐ x 10 /L (x 10 /mm )
9
3
3
235. Were platelets transfused ≤ 7 days before date of test?
☐ x 10 /L
6
236. Blasts in bone marrow
☐ Known
☐ Unknown
237. ___ ___ ___ %
CIBMTR Form 2402 revision 5 (page 31 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
238. Were cytogenetics tested (karyotyping or FISH)?
☐ Yes
☐ No
☐ Unknown
239. Were cytogenetics tested via FISH?
☐ Yes
☐ No
☐ Blood ☐ Bone Marrow
240. Sample source
241. Results of tests
☐ Abnormalities identified
☐ No abnormalities
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-
CIBMTR Form 2402 revision 5 (page 32 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ del(13q) / 13q-
☐ del(20q) / 20q-
Inversion
☐ inv(3)
Other
☐ i17q
☐ Other abnormality
245. Specify other abnormality:____________
246. Was documentation submitted to the CIBMTR? (e.g. FISH report)
☐ Yes ☐ No
247. Were cytogenetics tested via karyotyping?
☐ Yes
☐ No
☐ Blood ☐ Bone Marrow
248. Sample source
249. Results of tests
☐ Abnormalities identified
☐ No evaluable metaphases
☐ No abnormalities
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
CIBMTR Form 2402 revision 5 (page 33 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
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
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 259
☐ Hematologic improvement (HI) - Go to question 256
☐ No response (NR)/stable disease (SD) - Go to question 259
☐ Progression from hematologic improvement (Prog from HI) - Go to question 259
☐ Relapse from complete remission (Rel from CR) - Go to question 259
☐ Not assessed - Go to signature line
CIBMTR Form 2402 revision 5 (page 34 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
256. Specify the cell line examined to determine HI status (check all that apply)
☐ HI-E
☐ HI-P
☐ HI-N
257. Specify transfusion dependence
☐ Non transfused (NTD)
☐ Low transfusion burden (LTB)
☐ High transfusion burden (HTB)
258. Specify the response achieved
☐ Major response
☐ Minor response
259. Date assessed: ___ ___ ___ ___ / ___ ___ / ___ ___ - Go to signature line
YYYY
MM
DD
CIBMTR Form 2402 revision 5 (page 35 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Myeloproliferative Neoplasms (MPN)
260. 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)
☐ Chronic eosinophilic leukemia, not otherwise specified (NOS) (166)
☐ Essential thrombocythemia (58)
☐ Myeloproliferative neoplasm (MPN), unclassifiable (60)
☐ Myeloid / lymphoid neoplasms with PDGFRA rearrangement (1461)
☐ Myeloid / lymphoid neoplasms with PDGFRB rearrangement (1462)
☐ Myeloid / lymphoid neoplasms with FGFR1 rearrangement (1463)
☐ Myeloid / lymphoid neoplasms with PCM1-JAK2 (1464)
☐ Polycythemia vera (PCV) (57)
☐ Primary myelofibrosis (PMF) (167)
Mastocytosis
☐ Cutaneous mastocytosis (CM) (1465)
☐ Systemic mastocytosis (1470)
☐ Mast cell sarcoma (MCS) (1466)
262. Was documentation submitted to the CIBMTR?
(e.g. pathology report used for diagnosis)
☐ Yes ☐ No
261. Specify Systemic mastocytosis
☐ Indolent systemic mastocytosis (ISM)
☐ Smoldering systemic mastocytosis (SSM)
☐ Systemic mastocytosis with an associated hematological neoplasm
(SM-AHN)
☐ Aggressive systemic mastocytosis (ASM)
☐ Mast cell leukemia (MCL)
Assessment at diagnosis
263. Did the recipient have constitutional symptoms in six months before diagnosis? (symptoms are >10% weight loss in 6 months, night sweats,
unexplained fever higher than 37.5 °C)
☐ Yes
☐ No ☐ Unknown
Laboratory studies at diagnosis of MPN
264. Date CBC drawn:___ ___ ___ ___/ ___ ___ / ___ ___
YYYY
MM
DD
265. WBC
☐ Known
☐ Unknown
266. ___ ___ ___ ___ ___ ___ • ___
☐ x 10 /L (x 10 /mm )
9
3
3
☐ x 10 /L
6
267. Neutrophils
☐ Known
☐ Unknown
268. ___ ___%
269. Blasts in blood
☐ Known
☐ Unknown
270. ___ ___ ___ %
CIBMTR Form 2402 revision 5 (page 36 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
271. Hemoglobin
☐ Known
☐ Unknown
272. ___ ___ ___ ___ • ___ ___
☐ g/dL
☐ g/L
☐ mmol/L
273. Were RBCs transfused ≤ 30 days before date of test?
☐ Yes
☐ No
☐ Yes
☐ No
274. Platelets
☐ Known
☐ Unknown
275. ___ ___ ___ ___ ___ ___ ___
☐ x 10 /L (x 10 /mm )
9
3
3
☐ x 10 /L
6
276. Were platelets transfused ≤ 7 days before date of test?
277. Blasts in bone marrow
☐ Known
☐ Unknown
278. ___ ___ ___ %
279. Were tests for driver mutations performed?
☐ Yes
☐ No
☐ Unknown
280. JAK2
☐ Positive
☐ Negative
☐ Not done
281. JAK2 V617F
☐ Positive ☐ Negative
282. JAK2 Exon 12
☐ Positive ☐ Negative
☐ Not done
☐ Not done
283. CALR
☐ Positive
☐ Negative
☐ Not done
284. CALR type 1
☐ Positive ☐ Negative
285. CALR type 2
☐ Positive ☐ Negative
286. Not defined
☐ Positive ☐ Negative
287. MPL
288. CSF3R
289. Was documentation submitted to the CIBMTR?
☐ Not done
☐ Not done
☐ Not done
☐ Positive ☐ Negative ☐ Not done
☐ Positive ☐ Negative ☐ Not done
☐ Yes ☐ No
CIBMTR Form 2402 revision 5 (page 37 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
290. Were cytogenetics tested (karyotyping or FISH)?
☐ Yes
☐ No
☐ Unknown
291. Were cytogenetics tested via FISH?
☐ Yes
☐ No
☐ Blood ☐ Bone Marrow
292. Sample source
293. Results of tests
☐ Abnormalities identified
☐ No abnormalities
Specify cytogenetic abnormalities identified via FISH at diagnosis
294. International System for Human Cytogenetic Nomenclature (ISCN) _
compatible string:
_____________________________________________________
295. Specify number of distinct cytogenetic abnormalities
☐ One (1)
☐ Two (2)
☐ Three (3)
☐ Four or more (4 or more)
296. 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)
CIBMTR Form 2402 revision 5 (page 38 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Other
☐ i17q
☐ Other abnormality
297. Specify other abnormality:____________
298. Was documentation submitted to the CIBMTR? (e.g. FISH report)
☐ Yes ☐ No
299. Were cytogenetics tested via karyotyping?
☐ Yes
☐ No
☐ Blood ☐ Bone Marrow
300. Sample source
301. Results of tests
☐ Abnormalities identified
☐ No evaluable metaphases
☐ No abnormalities
Specify cytogenetic abnormalities identified via conventional
cytogenetics at diagnosis
302. International System for Human Cytogenetic Nomenclature (ISCN) _
compatible string:
_____________________________________________________
303. Specify number of distinct cytogenetic abnormalities
☐ One (1)
☐ Two (2)
☐ Three (3)
☐ Four or more (4 or more)
304. 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)
CIBMTR Form 2402 revision 5 (page 39 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
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
305. Specify other abnormality:____________
306. Was documentation submitted to the CIBMTR? (e.g. karyotyping report) ☐ Yes
☐ No
307. Did the recipient progress or transform to a different MPN subtype or AML between diagnosis and the start of the preparative regimen /
infusion?
☐ Yes
☐ No
308. Specify the MPN subtype or AML after transformation
☐ Post-essential thrombocythemic myelofibrosis (1467)
☐ Post-polycythemic myelofibrosis (1468)
☐ Transformed to AML (70)
309. Specify the date of the most recent
transformation:
___ ___ ___ ___/ ___ ___ / ___ ___
YYYY
MM
DD
- Go to question 311
310. Date of MPN diagnosis:
___ ___ ___ ___/ ___ ___ / ___ ___
YYYY
MM
DD
- Go to signature line
Assessment at last evaluation prior to the start of the preparative regimen / infusion
311. 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)
312. 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, unexplained fever higher than 37.5 °C)
☐ Yes
☐ No
☐ Unknown
CIBMTR Form 2402 revision 5 (page 40 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
313. Did the recipient have splenomegaly at last evaluation prior to the start of the preparative regimen/ infusion?
☐ Yes
☐ No
☐ Unknown
☐ Not applicable (splenectomy)
314. Specify the method used to measure spleen size
☐ Physical assessment
☐ Ultrasound
☐ CT/ MRI
315. Specify the spleen size: ___ ___ centimeters
below left costal margin
316. Specify the spleen size:___ ___ centimeters
317. Did the recipient have hepatomegaly at last evaluation prior to the start of the preparative regimen/infusion?
☐ Yes
☐ No
☐ Unknown
318. Specify the method used to measure liver size
☐ Physical assessment
319. Specify the liver size: ___ ___ centimeters
below left costal margin
☐ Ultrasound
☐ CT/ MRI
320. Specify the liver size:___ ___ centimeters
Laboratory studies at last evaluation prior to the start of the preparative regimen / infusion
321. Date CBC drawn:___ ___ ___ ___/ ___ ___ / ___ ___
YYYY
MM
DD
322. WBC
☐ Known
☐ Unknown
323. ___ ___ ___ ___ ___ ___ • ___
☐ x 10 /L (x 10 /mm )
9
3
3
☐ x 10 /L
6
324. Neutrophils
☐ Known
☐ Unknown
325. ___ ___%
326. Blasts in blood
☐ Known
☐ Unknown
327. ___ ___ ___ %
328. Hemoglobin
☐ Known
☐ Unknown
329. ___ ___ ___ ___ • ___ ___
☐ g/dL
☐ g/L
☐ mmol/L
330. Were RBCs transfused ≤ 30 days before date of test?
☐ Yes
☐ No
☐ Yes
☐ No
331. Platelets
☐ Known
☐ Unknown
332. ___ ___ ___ ___ ___ ___ ___
☐ x 10 /L (x 10 /mm )
9
3
3
333. Were platelets transfused ≤ 7 days before date of test?
☐ x 10 /L
6
334. Blasts in bone marrow
☐ Known
☐ Unknown
335. ___ ___ ___ %
CIBMTR Form 2402 revision 5 (page 41 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
336. Were tests for driver mutations performed?
☐ Yes
☐ No
☐ Unknown
337. JAK2
☐ Positive
☐ Negative
☐ Not done
338. JAK2 V617F
☐ Positive ☐ Negative
339. JAK2 Exon 12
☐ Positive ☐ Negative
☐ Not done
☐ Not done
340. CALR
☐ Positive
☐ Negative
☐ Not done
341. CALR type 1
☐ Positive ☐ Negative
342. CALR type 2
☐ Positive ☐ Negative
343. Not defined
☐ Positive ☐ Negative
344. MPL
345. CSF3R
346. Was documentation submitted to the CIBMTR?
☐ Not done
☐ Not done
☐ Not done
☐ Positive ☐ Negative ☐ Not done
☐ Positive ☐ Negative ☐ Not done
☐ Yes ☐ No
347. Were cytogenetics tested (karyotyping or FISH)?
☐ Yes
☐ No
☐ Unknown
348. Were cytogenetics tested via FISH?
☐ Yes
☐ No
☐ Blood ☐ Bone Marrow
349. Sample source
350. Results of tests
☐ Abnormalities identified
☐ No abnormalities
Specify cytogenetic abnormalities identified via FISH at last
evaluation prior to the start of the preparative regimen / infusion
351. International System for Human Cytogenetic Nomenclature (ISCN) _
compatible string:
_____________________________________________________
352. Specify number of distinct cytogenetic abnormalities
☐ One (1)
☐ Two (2)
☐ Three (3)
☐ Four or more (4 or more)
353. Specify abnormalities (check all that apply)
Monosomy
☐ –5
☐ –7
☐ –Y
CIBMTR Form 2402 revision 5 (page 42 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
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
354. Specify other abnormality:____________
355. Was documentation submitted to the CIBMTR? (e.g. FISH report)
☐ Yes ☐ No
356. Were cytogenetics tested via karyotyping?
☐ Yes
357. Sample source
☐ No
☐ Blood ☐ Bone Marrow
358. Results of tests
☐ Abnormalities identified
☐ No evaluable metaphases
☐ No abnormalities
Specify cytogenetic abnormalities identified via conventional
cytogenetics at last evaluation prior to the start of the preparative
regimen / infusion
359. International System for Human Cytogenetic Nomenclature (ISCN) _
compatible string:
_____________________________________________________
CIBMTR Form 2402 revision 5 (page 43 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
360. Specify number of distinct cytogenetic abnormalities
☐ One (1)
☐ Two (2)
☐ Three (3)
☐ Four or more (4 or more)
361. 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
362. Specify other abnormality:____________
363. Was documentation submitted to the CIBMTR? (e.g. karyotyping report) ☐ Yes
☐ No
CIBMTR Form 2402 revision 5 (page 44 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Status at transplantation / infusion
364. What was the disease status?
☐ Complete clinical remission (CR) - Go to question 368
☐ Partial clinical remission (PR) - Go to question 368
☐ Clinical Improvement (CI)
☐ Stable disease (SD) - Go to question 368
☐ Progressive disease - Go to question 368
☐ Relapse - Go to question 368
☐ Not assessed
365. Was an anemia response achieved?
366. Was a spleen response achieved?
367. Was a symptom response achieved?
☐ Yes
☐ Yes
☐ Yes
368. Date assessed: ___ ___ ___ ___/ ___ ___ / ___ ___
YYYY
MM
DD
369. Specify the cytogenetic response
☐ Complete response (CR): Eradication of pre-existing abnormality
☐ Partial response (PR): ≥ 50% reduction in abnormal metaphases
☐ Re-emergence of pre-existing cytogenetic abnormality
☐ Not assessed
☐ Not applicable
☐ None of the above (Does not meet the CR or PR criteria)
370. Date assessed:
___ ___ ___ ___/ ___ ___ / ___ ___
YYYY
MM
DD
371. Specify the molecular response
☐ Complete response (CR): Eradication of pre-existing abnormality
☐ Partial response (PR): ≥50% decrease in allele burden
☐ Re-emergence of a pre-existing molecular abnormality
☐ Not assessed - Go to First Name
☐ Not applicable - Go to First Name
☐ None of the above (Does not meet the CR or PR criteria)
372. Date assessed:
___ ___ ___ ___/ ___ ___ / ___ ___
YYYY
MM
DD
CIBMTR Form 2402 revision 5 (page 45 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
☐ No
☐ No
☐ No
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Other Leukemia (OL)
373. Specify the other leukemia classification
☐ Chronic lymphocytic leukemia (CLL), NOS (34) - Go to question 375
☐ Chronic lymphocytic leukemia (CLL), B-cell / small lymphocytic lymphoma (SLL) (71) - Go to question 375
☐ Hairy cell leukemia (35) - Go to question 378
☐ Hairy cell leukemia variant (75) - Go to question 378
☐ Monoclonal B-cell lymphocytosis (76) - Go to signature line
☐ Prolymphocytic leukemia (PLL), NOS (37) - Go to question 375
☐ PLL, B-cell (73) - Go to question 375
☐ PLL, T-cell (74) - Go to question 375
☐ Other leukemia, NOS (30) - Go to question 377
☐ Other leukemia (39) - Go to question 374
374. Specify other leukemia:_________________________________________________________ - Go to question 377
375. Was any 17p abnormality detected?
☐ Yes - If disease classification is CLL, go to question 376. If PLL, go to question 378.
☐ No
376. Did a histologic transformation to diffuse large B-cell lymphoma (Richter syndrome) occur at any time after
CLL diagnosis?
☐ Yes - Go to question 380 – Also complete NHL Disease Classification questions
☐ No - Go to question 378
Status at transplantation / infusion
377. What was the disease status? (Atypical CML)
☐ Primary induction failure - Go to question 379
☐ 1st complete remission (no previous bone marrow or extramedullary relapse) - Go to question 379
☐ 2nd complete remission - Go to question 379
☐ ≥ 3rd complete remission - Go to question 379
☐ 1st relapse - Go to question 379
☐ 2nd relapse - Go to question 379
☐ ≥ 3rd relapse - Go to question 379
☐ No treatment - Go to signature line
378. What was the disease status? (CLL, PLL, Hairy cell leukemia)
☐ Complete remission (CR) - Go to question 379
☐ Partial remission (PR) - Go to question 379
☐ Stable disease (SD) - Go to question 379
☐ Progressive disease (Prog) - Go to question 379
☐ Untreated - Go to question 379
☐ Not assessed - Go to signature line
379. Date assessed: __ __ __ __ / __ __ / __ __ - Go to signature line
YYYY
MM DD
CIBMTR Form 2402 revision 5 (page 46 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Hodgkin and Non-Hodgkin Lymphoma
380. 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 382
☐ Diffuse, large B-cell lymphoma - Germinal center B-cell type (1820) - Go to question 382
☐ Diffuse large B-cell Lymphoma (cell of origin unknown) (107)
☐ DLBCL associated with chronic inflammation (1825)
☐ Duodenal-type follicular lymphoma (1815)
☐ EBV+ DLBCL, NOS (1823)
☐ EBV+ mucocutaneous ulcer (1824)
☐ Extranodal marginal zone B-cell lymphoma of mucosal associated lymphoid tissue type (MALT) (122)
☐ Follicular, mixed, small cleaved and large cell (Grade II follicle center lymphoma) (103)
☐ Follicular, predominantly large cell (Grade IIIA follicle center lymphoma) (162)
☐ Follicular, predominantly large cell (Grade IIIB follicle center lymphoma) (163)
☐ Follicular, predominantly large cell (Grade IIIA vs IIIB not specified) (1814)
☐ Follicular, predominantly small cleaved cell (Grade I follicle center lymphoma) (102)
☐ Follicular (grade unknown) (164)
☐ HHV8+ DLBCL, NOS (1826)
☐ High-grade B-cell lymphoma, with MYC and BCL2 and/or BCL6 rearrangements (1831)
☐ High-grade B-cell lymphoma, NOS (1830)
☐ Intravascular large B-cell lymphoma (136)
☐ Large B-cell lymphoma with IRF4 rearrangement (1832)
☐ Lymphomatoid granulomatosis (1835)
☐ Mantle cell lymphoma (115)
☐ Nodal marginal zone B-cell lymphoma (± monocytoid B-cells) (123)
☐ Pediatric nodal marginal zone lymphoma (1813)
☐ Pediatric-type follicular lymphoma (1816)
☐ Plasmablastic lymphoma (1836)
☐ Primary cutaneous DLBCL, leg type (1822)
☐ Primary cutaneous follicle center lymphoma (1817)
☐ Primary diffuse, large B-cell lymphoma of the CNS (118)
☐ Primary effusion lymphoma (138)
☐ Primary mediastinal (thymic) large B-cell lymphoma (125)
CIBMTR Form 2402 revision 5 (page 47 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ Splenic B-cell lymphoma/leukemia, unclassifiable (1811)
☐ Splenic diffuse red pulp small B-cell lymphoma (1812)
☐ Splenic marginal zone B-cell lymphoma (124)
☐ T-cell / histiocytic rich large B-cell lymphoma (120)
☐ Waldenstrom macroglobulinemia / Lymphoplasmacytic lymphoma (173)
☐ Other B-cell lymphoma (129) - Go to question 381
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 381
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)
381. Specify other lymphoma histology: ________________________________________________ - Go to question 383
382. 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
CIBMTR Form 2402 revision 5 (page 48 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
383. Is the lymphoma histology reported at transplant a transformation from CLL?
☐ Yes
☐ No
384. Was any 17p abnormality detected?
☐ Yes
☐ No
385. Is the lymphoma histology reported at transplant a transformation from a different lymphoma histology? (Not CLL)
☐ Yes
☐ No
386. Specify the original lymphoma histology (prior to transformation)
Hodgkin Lymphoma Codes
☐ Hodgkin lymphoma, not otherwise specified (150)
☐ Lymphocyte depleted (154)
☐ Lymphocyte-rich (151)
☐ Mixed cellularity (153)
☐ Nodular lymphocyte predominant Hodgkin lymphoma (155)
☐ Nodular sclerosis (152)
Non-Hodgkin Lymphoma Codes
B-cell Neoplasms
☐ ALK+ large B-cell lymphoma (1833)
☐ Burkitt lymphoma (111)
☐ Burkitt-like lymphoma with 11q aberration (1834)
☐ Diffuse, large B-cell lymphoma - Activated B-cell type (non-GCB) (1821) - Go to question 387
☐ Diffuse, large B-cell lymphoma - Germinal center B-cell type (1820) - Go to question 387
☐ Diffuse large B-cell Lymphoma (cell of origin unknown) (107)
☐ DLBCL associated with chronic inflammation (1825)
☐ Duodenal-type follicular lymphoma (1815)
☐ EBV+ DLBCL, NOS (1823)
☐ EBV+ mucocutaneous ulcer (1824)
☐ Extranodal marginal zone B-cell lymphoma of mucosal associated lymphoid tissue type (MALT) (122)
☐ Follicular, mixed, small cleaved and large cell (Grade II follicle center lymphoma) (103)
☐ Follicular, predominantly large cell (Grade IIIA follicle center lymphoma) (162)
☐ Follicular, predominantly large cell (Grade IIIB follicle center lymphoma) (163)
☐ Follicular, predominantly large cell (Grade IIIA vs IIIB not specified) (1814)
☐ Follicular, predominantly small cleaved cell (Grade I follicle center lymphoma) (102)
☐ Follicular (grade unknown) (164)
☐ HHV8+ DLBCL, NOS (1826)
☐ High-grade B-cell lymphoma, with MYC and BCL2 and/or BCL6 rearrangements (1831)
☐ High-grade B-cell lymphoma, NOS (1830)
☐ Intravascular large B-cell lymphoma (136)
☐ Large B-cell lymphoma with IRF4 rearrangement (1832)
☐ Lymphomatoid granulomatosis (1835)
☐ Mantle cell lymphoma (115)
☐ Nodal marginal zone B-cell lymphoma (± monocytoid B-cells) (123)
☐ Pediatric nodal marginal zone lymphoma (1813)
☐ Pediatric-type follicular lymphoma (1816)
☐ B-cell lymphoma, unclassifiable, with features intermediate between DLBCL and classical Hodgkin
lymphoma (149)
CIBMTR Form 2402 revision 5 (page 49 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ Plasmablastic lymphoma (1836)
☐ Primary cutaneous DLBCL, leg type (1822)
☐ Primary cutaneous follicle center lymphoma (1817)
☐ Primary diffuse, large B-cell lymphoma of the CNS (118)
☐ Primary effusion lymphoma (138)
☐ Primary mediastinal (thymic) large B-cell lymphoma (125)
☐ Splenic B-cell lymphoma/leukemia, unclassifiable (1811)
☐ Splenic diffuse red pulp small B-cell lymphoma (1812)
☐ Splenic marginal zone B-cell lymphoma (124)
☐ T-cell / histiocytic rich large B-cell lymphoma (120)
☐ Waldenstrom macroglobulinemia / Lymphoplasmacytic lymphoma (173)
☐ Other B-cell lymphoma (129) - Go to question 387
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 387
Posttransplant lymphoproliferative disorders (PTLD)
☐ Classical Hodgkin lymphoma PTLD (1876)
☐ Florid follicular hyperplasia PTLD (1873)
☐ Infectious mononucleosis PTLD (1872)
CIBMTR Form 2402 revision 5 (page 50 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ Monomorphic PTLD (B- and T-/NK-cell types) (1875)
☐ Plasmacytic hyperplasia PTLD (1871)
☐ Polymorphic PTLD (1874)
387. Specify other lymphoma histology:___________________________
388. Date of original lymphoma diagnosis: __ __ __ __ / __ __ / __ __
YYYY
MM DD
(report the date of diagnosis of original lymphoma subtype)
389. Was a PET (or PET/CT) scan performed? (at last evaluation prior to the start of the preparative regimen / infusion)
☐ Yes
☐ No
390. Was the PET (or PET/CT) scan positive for lymphoma involvement at any disease site?
☐ Yes
☐ No
391. Date of PET scan
☐ Known
☐ Unknown
392. Date of PET (or PET/CT) scan: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
393. Deauville (five-point) score of the PET (or PET/CT) scan
☐ Known
☐ Unknown
394. 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
395. 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 396
☐ PIF sen / PR1 - Primary induction failure – sensitive: NEVER in COMPLETE remission but with partial remission on treatment.
- Go to question 396
☐ PIF unk - Primary induction failure – sensitivity unknown - Go to question 396
☐ CR1 - 1st complete remission: no bone marrow or extramedullary relapse prior to transplant - Go to question 396
☐ CR2 - 2nd complete remission - Go to question 396
☐ CR3+ - 3rd or subsequent complete remission - Go to question 396
☐ REL1 unt - 1st relapse – untreated; includes either bone marrow or extramedullary relapse - Go to question 396
☐ REL1 res - 1st relapse – resistant: stable or progressive disease with treatment - Go to question 396
☐ REL1 sen - 1st relapse – sensitive: partial remission (if complete remission was achieved, classify as CR2) - Go to question 396
☐ REL1 unk - 1st relapse – sensitivity unknown - Go to question 396
☐ REL2 unt - 2nd relapse – untreated: includes either bone marrow or extramedullary relapse - Go to question 396
☐ REL2 res - 2nd relapse – resistant: stable or progressive disease with treatment - Go to question 396
CIBMTR Form 2402 revision 5 (page 51 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
☐ REL2 sen - 2nd relapse – sensitive: partial remission (if complete remission achieved, classify as CR3+) - Go to question 396
☐ REL2 unk - 2nd relapse – sensitivity unknown - Go to question 396
☐ REL3+ unt - 3rd or subsequent relapse – untreated; includes either bone marrow or extramedullary relapse - Go to question 396
☐ REL3+ res - 3rd or subsequent relapse – resistant: stable or progressive disease with treatment - Go to question 396
☐ REL3+ sen - 3rd or subsequent relapse – sensitive: partial remission (if complete remission achieved, classify as CR3+)
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
- Go to question 396
☐ REL3+ unk - 3rd relapse or greater – sensitivity unknown - Go to question 396
396. Total number of lines of therapy received (between diagnosis and HCT / infusion)
☐ 1 line ☐ 2 lines
☐ 3+ lines
397. Date assessed: __ __ __ __ / __ __ / __ __ - Go to signature line
YYYY
MM
DD
CIBMTR Form 2402 revision 5 (page 52 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Multiple Myeloma / Plasma Cell Disorder (PCD)
398. Specify the multiple myeloma / plasma cell disorder (PCD) classification:
☐ Multiple myeloma (178) - Go to questions 400
☐ Multiple myeloma-light chain only (186) - Go to questions 400
☐ Multiple myeloma-non-secretory (187) - Go to questions 406
☐ Plasma cell leukemia (172) - Go to questions 408
☐ Solitary plasmacytoma (no evidence of myeloma) (175) - Go to questions 405
☐ Smoldering myeloma (180) - Go to questions 408
☐ Amyloidosis (174) - Go to questions 401
☐ Osteosclerotic myeloma / POEMS syndrome (176) - Go to question 408
☐ Monoclonal gammopathy of renal significance (MGRS) (1611) - Go to question 402
☐ Other plasma cell disorder (179) - Go to question 399
399. Specify other plasma cell disorder:________________________________________________ - Go to question 408
400. Specify heavy and/or light chain type (check all that apply)
☐ IgG kappa
☐ IgA kappa
☐ IgM kappa
☐ IgD kappa
☐ IgE kappa
☐ IgG lambda
☐ IgA lambda
☐ IgM lambda
☐ IgD lambda
☐ IgE lambda
☐ IgG (heavy chain only)
☐ IgA (heavy chain only)
☐ IgM (heavy chain only)
☐ IgD (heavy chain only)
☐ IgE (heavy chain only)
☐ Kappa (light chain only)
☐ Lambda (light chain only)
- Go to question 406
401. Specify Amyloidosis classification
☐ AL amyloidosis
- Go to question 408
☐ AH amyloidosis
☐ AHL amyloidosis
402. Select monoclonal gammopathy of renal significance (MGRS) classification
☐ Light chain fanconi syndrome - Go to question 404
☐ Proximal tubulopathy without crystals - Go to question 404
☐ Crystal-storing histiocytosis - Go to question 404
☐ Non-amyloid fibrillary glomerulonephritis - Go to question 404
☐ Immunotactoid glomerulopathy (ITGN)/ Glomerulonephritis with organized monoclonal microtubular
immunoglobulin deposits (GOMMID) - Go to question 404
☐ Type 1 cryoglobulinemic glomerulonephritis - Go to question 404
☐ Monoclonal immunoglobulin deposition disease (MIDD) - Go to question 403
CIBMTR Form 2402 revision 5 (page 53 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ Proliferative glomerulonephritis with monoclonal immunoglobulin G deposits (PGNMID)
- Go to question 404
☐ C3 glomerulopathy with monoclonal gammopathy - Go to question 404
☐ Unknown - Go to question 404
403. Select monoclonal immunoglobulin deposition disease (MIDD) subtype
☐ Light chain deposition disease (LCDD)
☐ Light and heavy chain deposition disease (LHCDD)
☐ Heavy chain deposition disease (HCDD)
404. Was documentation submitted to the CIBMTR? (e.g. pathology report)
☐ Yes - Go to question 408
405. Solitary plasmacytoma was
☐ Extramedullary - Go to question 408
☐ No - Go to question 408
☐ Bone derived - Go to question 408
406. 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 407
☐ Stage II (Fitting neither Stage I or Stage III) - Go to question 407
☐ Unknown - Go to question 408
☐ 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 407
407. 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)
408. Did the recipient have a preceding or concurrent plasma cell disorder?
☐ Yes
☐ No
409. Specify preceding / concurrent disorder
☐ Multiple myeloma
☐ Multiple myeloma-light chain only
☐ Multiple myeloma-non-secretory
☐ Plasma cell leukemia
☐ Solitary plasmacytoma (no evidence of myeloma)
☐ Smoldering myeloma
☐ Amyloidosis
☐ Osteosclerotic myeloma / POEMS syndrome
☐ Monoclonal gammopathy of unknown significance (MGUS)
☐ Monoclonal gammopathy of renal significance (MGRS)
☐ Other plasma cell disorder (PCD)
410. Specify other preceding / concurrent disorder: _____________________________________
411. Date of diagnosis of preceding / concurrent disorder: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
Copy questions 409 - 411 to report more than one concurrent or preceding disorder.
CIBMTR Form 2402 revision 5 (page 54 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
412. Serum β2-microglobulin
☐ Known
☐ Unknown
413. Serum β2-microglobulin: ___ ___ ___ • ___ ___ ___
☐ μg/dL
☐ mg/L
☐ nmol/L
414. Serum albumin
☐ Known
☐ Unknown
415. Serum albumin: ___ ___ • ___
☐ g/dL
☐ g/L
I.S.S. at diagnosis
416. Stage
☐ Known
☐ Unknown
417. Stage
☐ 1 (β2-mic < 3.5, S. albumin ≥ 3.5)
☐ 2 (not fitting stage 1 or 3)
☐ 3 (β2-mic ≥ 5.5; S. albumin —)
R - I.S.S. at diagnosis
418. Stage
☐ Known
☐ Unknown
419. Stage
☐ 1 (ISS stage I and standard-risk chromosomal abnormalities by iFISH and normal
LDH levels)
☐ 2 (Not R-ISS stage I or III)
☐ 3 (ISS stage III and either high-risk chromosomal abnormalities by iFISH or high LDH
levels)
420. Plasma cells in blood by flow cytometry
☐ Known
☐ Unknown
421. ___ ___ • ___ ___%
422. ___ ___ ___ ___ ___ • ___ ___ ☐ x 109/L (x 103/mm3)
☐ x 10 /L
6
423. Plasma cells in blood by morphologic assessment
☐ Known
☐ Unknown
424. ___ ___%
425. ___ ___ ___ ___ ___ • ___ ___
☐ x 10 /L (x 10 /mm )
9
3
3
☐ x 10 /L
6
426. LDH
☐ Known
☐ Unknown
427. ___ ___ ___ ___ ___ • ___ ___ ☐ U/L
428.
☐ μkat/L
Upper limit of normal for LDH: ___ ___ ___ ___ ___ • ___ ___
CIBMTR Form 2402 revision 5 (page 55 of 71). FOMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Labs at diagnosis
429. Were cytogenetics tested (karyotyping or FISH)? (at diagnosis)
☐ Yes
☐ No
☐ Unknown
430. Were cytogenetics tested via FISH?
☐ Yes
☐ No
431. Results of tests
☐ Abnormalities identified
☐ No abnormalities
Specify cytogenetic abnormalities identified
via FISH at diagnosis
432. International System for Human
Cytogenetic Nomenclature (ISCN)
compatible string:____________________
433. 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-
☐ - 13
☐ - 17
☐ del (17)/17p
Monosomy
Other
☐ Hyperdiploid (>50)
☐ Hypodiploid (<46)
☐ MYC rearrangement
☐ Any abnormality at 1q
☐ Any abnormality at 1p
☐ Other abnormality
434. Specify other
abnormality:
________________
CIBMTR Form 2402 revision 5 (page 56 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ Yes
435. Was documentation submitted to the CIBMTR? (e.g. FISH report)
☐ No
436. Were cytogenetics tested via karyotyping?
☐ Yes
☐ No
437. Results of tests
☐ Abnormalities identified
☐ No evaluable metaphases
☐ No abnormalities
Specify cytogenetic abnormalities identified
via conventional cytogenetics at diagnosis
438. International System for Human
Cytogenetic Nomenclature (ISCN)
compatible string:_____________________
439. 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-
☐ - 13
☐ - 17
☐ del (17)/17p
Monosomy
Other
☐ Hyperdiploid (>50)
☐ Hypodiploid (<46)
☐ MYC rearrangement
☐ Any abnormality at 1q
☐ Any abnormality at 1p
☐ Other abnormality
440. Specify other
abnormality:
______________
CIBMTR Form 2402 revision 5 (page 57 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
441. Was documentation submitted to the CIBMTR? (e.g. karyotyping report)
☐ Yes ☐ No
Status at transplantation / infusion
442. What is the hematologic disease status?
☐ Stringent complete response (sCR)
☐ Complete response (CR)
☐ Very good partial response (VGPR )
☐ Partial response (PR)
☐ No reponse (NR) / Stable disease (SD)
☐ Progressive disease (PD)
☐ Relapse from CR (Rel) (untreated)
☐ Unknown
443. Date assessed: __ __ __ __ / __ __ / __ __ - Go to signature line
YYYY
MM
DD
444. Specify amyloidosis hematologic response? (for Amyloid patients only)
☐ Complete response (CR)
☐ Very good partial response (VGPR)
☐ Partial response (PR)
☐ No reponse (NR) / Stable disease (SD)
☐ Progressive disease (PD)
☐ Relapse from CR (Rel) (untreated)
☐ Unknown
445. Date assessed: __ __ __ __ / __ __ / __ __ - Go to signature line
YYYY
MM
DD
CIBMTR Form 2402 revision 5 (page 58 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Solid Tumors
446. 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)
447. Specify other solid tumor:______________________________________
- Go to signature line
CIBMTR Form 2402 revision 5 (page 59 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Severe Aplastic Anemia
448. Specify the severe aplastic anemia classification
☐ Acquired severe aplastic anemia, not otherwise specified (301)
☐ Acquired SAA secondary to hepatitis (302)
☐ Acquired SAA secondary to toxin / other drug (303)
☐ Acquired amegakaryocytosis (not congenital) (304)
☐ Acquired pure red cell aplasia (not congenital) (306)
☐ Dyskeratosis congenita (307)
☐ Other acquired cytopenic syndrome (309)
449. Specify other acquired cytopenic syndrome:______________________
- Go to signature line
CIBMTR Form 2402 revision 5 (page 60 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Inherited Abnormalities of Erythrocyte Differentiation or Function
450. Specify the inherited abnormalities of erythrocyte differentiation or function classification
☐ Paroxysmal nocturnal hemoglobinuria (PNH) (56) - Go to signature line
☐ Shwachman-Diamond (305) - Go to question 453
☐ Diamond-Blackfan anemia (pure red cell aplasia) (312) - Go to question 453
☐ Other constitutional anemia (319) - Go to question 451
☐ Fanconi anemia (311) (If the recipient developed MDS or AML, indicate MDS or AML as the primary disease) - Go to question 453
☐ Sickle thalassemia (355) - Go to question 453
☐ Sickle cell disease (356) - Go to question 453
☐ Beta thalassemia major (357) - Go to question 453
☐ Other hemoglobinopathy (359) - Go to question 452
451. Specify other constitutional anemia:______________________________________________ - Go to question 453
452. Specify other hemoglobinopathy:_________________________________________________ - Go to question 453
453. Did the recipient receive gene therapy to treat the inherited abnormalities of erythrocyte differentiation or function?
☐ Yes – Also complete Cellular Therapy Product and Infusion forms 4003 and 4006. If sickle cell or sickle
thalassemia, go to question 454. If beta thalassemia, go to question 457, else go to signature line
☐ No - If sickle cell or sickle thalassemia, go to question 454. If beta thalassemia, go to question 457, else go _
to signature line
454. Was tricuspid regurgitant jet velocity (TRJV) measured by echocardiography pre-HCT? (sickle cell, sickle
thalassemia and beta thalassemia major only)
☐ Yes
☐ No
☐ Unknown
455. TRJV measurement
☐ Known
☐ Unknown
456. TRJV measurement: __ __ m/sec
457. Was liver iron content (LIC) tested within 6 months prior to infusion? (sickle cell, sickle thalassemia, beta
thalassemia major only)
☐ Yes
☐ No
458. Liver iron content ___ ___ ___ mg iron / g liver dry weight
459. Method used to estimate LIC?
☐ T2*MRI
☐ SQUID MRI
☐ FerriScan
☐ Liver biopsy ☐ Other
CIBMTR Form 2402 revision 5 (page 61 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Beta thalassemia major
460. Is the recipient red blood cell transfusion dependent? (requiring transfusion to maintain HGB >7g/dL)
☐ Yes
☐ No
461. Year of first transfusion (since diagnosis): ___ ___ ___ ___
YYYY
462. Was iron chelation therapy given at any time since diagnosis?
☐ Yes
☐ No
☐ Unkown
463. 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
- Go to question 466
☐ No, iron chelation therapy given, but not meeting criteria
listed - Go to question 464
☐ Iron chelation therapy given, but details of administration
unknown - Go to question 466
464. Specify reason criteria not met
☐ Non-adherence - Go to question 466
☐ Toxicity due to iron chelation therapy
- Go to question 466
☐ Other, specify
465. Specify other reason criteria
not met:
________________________
466. Year iron chelation therapy started
☐ Known
☐ Unknown
467. Year started: ___ ___ ___ ___
_ YYYY
468. Did the recipient have hepatomegaly? (≥ 2 cm below costal margin)
☐ Yes
☐ No
☐ Unknown
469. Liver size as measured below the costal margin at most recent evaluation prior to
infusion: ___ ___ cm
470. Was a liver biopsy performed at any time since diagnosis?
☐ Yes
☐ No
471. Date assessed
☐ Known
☐ Unknown
472. Date assessed: __ __ __ __ / __ __ / __ __ ☐ Date estimated
YYYY
MM
DD
☐ Absent ☐ Unknown
☐ Absent ☐ Unknown
475. Chronic hepatitis
☐ Absent ☐ Unknown
476. Was documentation submitted to the CIBMTR? (e.g., liver biopsy)
☐ Yes ☐ No
473. Liver cirrhosis
474. Bridging fibrosis
☐ Present
☐ Present
☐ Present
CIBMTR Form 2402 revision 5 (page 62 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
477. Is there evidence of abnormal cardiac iron deposition based on MRI of the heart at time of infusion?
☐ Yes
☐ No
478. Did patient have a splenectomy at any time prior to infusion?
☐ Yes
☐ No
☐ Unknown
☐ Yes
☐ No
☐ Unknown
Laboratory studies at last evaluation prior to start of preparative regimen
479. Serum Iron
☐ Known
☐ Unknown
480. ___ ___ ___ ☐ µg / dL
☐ µmol / L
481. Total iron binding capacity (TIBC)
☐ Known
☐ Unknown
482. ___ ___ ___ ☐ µg / dL
☐ µmol / L
483. Was serum bilirubin less than two times the upper limit of normal?
CIBMTR Form 2402 revision 5 (page 63 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Disorders of the Immune System
484. Specify disorder of immune system classification
☐ Adenosine deaminase (ADA) deficiency / severe combined immunodeficiency (SCID) (401) - Go to question 488
☐ Absence of T and B cells SCID (402) - Go to question 488
☐ Absence of T, normal B cell SCID (403) - Go to question 488
☐ Omenn syndrome (404) - Go to question 488
☐ Reticular dysgenesis (405) - Go to question 488
☐ Bare lymphocyte syndrome (406) - Go to question 488
☐ Other SCID (419) - Go to question 485
☐ SCID, not otherwise specified (410) - Go to question 488
☐ Ataxia telangiectasia (451) - Go to question 488
☐ HIV infection (452) - Go to question 488
☐ DiGeorge anomaly (454) - Go to question 488
☐ Common variable immunodeficiency (457) - Go to question 488
☐ Leukocyte adhesion deficiencies, including GP180, CD-18, LFA and WBC adhesion deficiencies (459) - Go to question 488
☐ Kostmann agranulocytosis (congenital neutropenia) (460) - Go to question 488
☐ Neutrophil actin deficiency (461) - Go to question 488
☐ Cartilage-hair hypoplasia (462) - Go to question 488
☐ CD40 ligand deficiency (464) - Go to question 488
☐ Other immunodeficiencies (479) - Go to question 486
☐ Immune deficiency, not otherwise specified (400) - Go to question 488
☐ Chediak-Higashi syndrome (456) – Also complete Pigmentary Dilution Disorder (PDD) Pre-HCT Data Form - Go to question 488
☐ Griscelli syndrome type 2 (465) – Also complete Pigmentary Dilution Disorder (PDD) Pre-HCT Data Form - Go to question 488
☐ Hermansky-Pudlak syndrome type 2 (466) – Also complete Pigmentary Dilution Disorder (PDD) Pre-HCT Data Form
- Go to question 488
☐ Other pigmentary dilution disorder (469) – Also complete Pigmentary Dilution Disorder (PDD) Pre-HCT Data Form
- Go to question 487
☐ Chronic granulomatous disease (455) - Go to question 488
☐ Wiskott-Aldrich syndrome (453) - Go to question 488
☐ X-linked lymphoproliferative syndrome (458) - Go to question 488
485. Specify other SCID:____________________________________________________________ - Go to question 488
486. Specify other immunodeficiency:__________________________________________________ - Go to question 488
487. Specify other pigmentary dilution disorder:__________________________________________ - Go to question 488
488. Did the recipient have an active or recent infection with a viral pathogen within 60 days of HCT?
☐ Yes
☐ No
489. Specify viral pathogen (check all that apply)
☐ 304 Adenovirus
☐ 341 BK Virus
☐ 344 Coronavirus
☐ 303 Cytomegalovirus (CMV)
☐ 347 Chikaugunya Virus
☐ 346 Dengue Virus
☐ 325 Enterovirus (ECHO, Coxsackie)
☐ 327 Enterovirus D68 (EV-D68)
CIBMTR Form 2402 revision 5 (page 64 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ 326 Enterovirus (polio)
☐ 328 Enterovirus NOS
☐ 318 Epstein-Barr Virus (EBV)
☐ 306 Hepatitis A Virus
☐ 307 Hepatitis B Virus
☐ 308 Hepatitis C Virus
☐ 340 Hepatitis E
☐ 301 Herpes Simplex Virus (HSV)
☐ 317 Human herpesvirus 6 (HHV-6)
☐ 309 Human Immunodeficiency Virus 1 or 2
☐ 343 Human metapneumovirus
☐ 322 Human Papillomavirus (HPV)
☐ 349 Human T-lymphotropic Virus 1 or 2
☐ 310 Influenza, NOS
☐ 323 Influenza A Virus
☐ 324 Influenza B Virus
☐ 342 JC Virus (Progressive Multifocal Leukoencephalopathy (PML))
☐ 311 Measles Virus (Rubeola)
☐ 312 Mumps Virus
☐ 345 Norovirus
☐ 316 Human Parainfluenza Virus (all species)
☐ 314 Respiratory Syncytial Virus (RSV)
☐ 321 Rhinovirus (all species)
☐ 320 Rotavirus (all species)
☐ 315 Rubella Virus
☐ 302 Varicella Virus
☐ 348 West Nile Virus (WNV)
490. Has the recipient ever been infected with PCP/PJB?
491. Does the recipient have GVHD due to maternal cell engraftment pre-HCT? (SCID only)
☐ Yes
☐ Yes
CIBMTR Form 2402 revision 5 (page 65 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
☐ No
☐ No
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Inherited Abnormalities of Platelets
492. Specify inherited abnormalities of platelets classification
☐ Congenital amegakaryocytosis / congenital thrombocytopenia (501)
☐ Glanzmann thrombasthenia (502)
☐ Other inherited platelet abnormality (509)
493. Specify other inherited platelet abnormality:______________________
- Go to signature line
CIBMTR Form 2402 revision 5 (page 66 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Inherited Disorders of Metabolism
494. Specify inherited disorders of metabolism classification
☐ Osteopetrosis (malignant infantile osteopetrosis) (521)
Leukodystrophies
☐ Metachromatic leukodystrophy (MLD) (542)
☐ Adrenoleukodystrophy (ALD) (543)
☐ Krabbe disease (globoid leukodystrophy) (544)
☐ Lesch-Nyhan (HGPRT deficiency) (522)
☐ Neuronal ceroid lipofuscinosis (Batten disease) (523)
Mucopolysaccharidoses
☐ Hurler syndrome (IH) (531)
☐ Scheie syndrome (IS) (532)
☐ Hunter syndrome (II) (533)
☐ Sanfilippo (III) (534)
☐ Morquio (IV) (535)
☐ Maroteaux-Lamy (VI) (536)
☐ β-glucuronidase deficiency (VII) (537)
☐ Mucopolysaccharidosis (V) (538)
☐ Mucopolysaccharidosis, not otherwise specified (530)
Mucolipidoses
☐ Gaucher disease (541)
☐ Niemann-Pick disease (545)
☐ I-cell disease (546)
☐ Wolman disease (547)
☐ Glucose storage disease (548)
☐ Mucolipidoses, not otherwise specified (540)
Polysaccharide hydrolase abnormalities
496. Loes composite score: __ __ Adrenoleukodystrophy (ALD) only
- Go to signature line
☐ Aspartyl glucosaminidase (561)
☐ Fucosidosis (562)
☐ Mannosidosis (563)
☐ Polysaccharide hydrolase abnormality, not otherwise specified (560)
☐ Other inherited metabolic disorder (529)
☐ Inherited metabolic disorder, not otherwise specified (520)
495. Specify other inherited metabolic disorder:
_______________________________________
- Go to signature line
CIBMTR Form 2402 revision 5 (page 67 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Histiocytic disorders
497. Specify histiocytic disorder classification
☐ Hemophagocytic lymphohistiocytosis (HLH) (571) - Go to question 499
☐ Langerhans cell histiocytosis (histiocytosis-X) (572)
☐ Hemophagocytosis (reactive or viral associated) (573)
☐ Malignant histiocytosis (574)
☐ Other histiocytic disorder (579) - Go to question 498
☐ Histiocytic disorder, not otherwise specified (570)
498. Specify other histiocytic disorder:_________________________________________________- Go to signature line
499. Did the recipient have an active or recent infection with a viral pathogen within 60 days of HCT?
Hemophagocytic lymphohistiocytosis (HLH) only
☐ Yes
☐ No
500. Specify viral pathogen (check all that apply)
☐ 304 Adenovirus
☐ 341 BK Virus
☐ 344 Coronavirus
☐ 303 Cytomegalovirus (CMV)
☐ 347 Chikaugunya Virus
☐ 346 Dengue Virus
☐ 325 Enterovirus (ECHO, Coxsackie)
☐ 327 Enterovirus D68 (EV-D68)
☐ 326 Enterovirus (polio)
☐ 328 Enterovirus NOS
☐ 318 Epstein-Barr Virus (EBV)
☐ 306 Hepatitis A Virus
☐ 307 Hepatitis B Virus
☐ 308 Hepatitis C Virus
☐ 340 Hepatitis E
☐ 301 Herpes Simplex Virus (HSV)
☐ 317 Human herpesvirus 6 (HHV-6)
☐ 309 Human Immunodeficiency Virus 1 or 2
☐ 343 Human metapneumovirus
☐ 322 Human Papillomavirus (HPV)
☐ 349 Human T-lymphotropic Virus 1 or 2
☐ 310 Influenza, NOS
☐ 323 Influenza A Virus
☐ 324 Influenza B Virus
☐ 342 JC Virus (Progressive Multifocal Leukoencephalopathy (PML))
☐ 311 Measles Virus (Rubeola)
☐ 312 Mumps Virus
☐ 345 Norovirus
☐ 316 Human Parainfluenza Virus (all species)
☐ 314 Respiratory Syncytial Virus (RSV)
☐ 321 Rhinovirus (all species)
CIBMTR Form 2402 revision 5 (page 68 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ 320 Rotavirus (all species)
☐ 315 Rubella Virus
☐ 302 Varicella Virus
☐ 348 West Nile Virus (WNV)
501. Has the recipient ever been infected with PCP/PJB?
- Go to signature line
☐ Yes
CIBMTR Form 2402 revision 5 (page 69 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
☐ No
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Autoimmune Diseases
502. 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 503
Bowel diseases
☐ Crohn’s disease (649)
☐ Ulcerative colitis (650)
☐ Other autoimmune bowel disorder (651) - Go to question 504
CIBMTR Form 2402 revision 5 (page 70 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Metabolic
☐ Diabetes mellitus type 1 (660)
Other
☐ Other autoimmune disease (629) - Go to question 505
503. Specify other autoimmune cytopenia:_______________________________________________________________
504. Specify other autoimmune bowel disorder:___________________________________________________________
505. Specify other autoimmune disease:_________________________________________________________________
- Go to signature line
Tolerance Induction Associated with Solid Organ Transplant
506. Specify transplanted organ (check all that apply)
☐ Kidney
☐ Liver
☐ Pancreas
☐ Other organ
507. Other organ, specify:__________________________________________________________
- Go to signature line
Other Disease
508. Specify other disease:_____________________________________________________________________________ - Go to signature line
First Name:______________________________________________________________
Last Name:_______________________________________________________________
E-mail address:___________________________________________________________
Date: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
CIBMTR Form 2402 revision 5 (page 71 of 71). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated July, 2020. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
| File Type | application/pdf |
| File Modified | 2020-07-16 |
| File Created | 2020-07-16 |