PATIENT DATA
Date of this report
date
Patient following national / international study / trial
integer
Name of study / trial
text
Hospital Unique Patient Number/Code
text
Initials
text
PersonBirthDate
date
Sex
text
DISEASE
HSCT
Performance score
integer
Score
text
Type of HSCT
integer
Patient CMV status
text
Multiple donors/products
boolean
Multiple donors/products
text
STEM CELLS (autograft or allograft)
Source of Stem Cells
text
Source of Stem Cells
text
Donor ID
text
Donor ID
integer
HLA match type
text
Degree of mismatch
integer
Name of donor registry/CB Bank
text
BMDW/WMDA code (up to 4 characters)
text
Number of mismatches
text
Number of mismatches
text
Number of mismatches
text
Number of mismatches
text
Number of mismatches
text
Number of mismatches
text
Donor Sex
text
Donor age ys
integer
Graft manipulation ex-vivo (including T-cell depletion) other than for RBC removal or volume reduction
boolean
HSCT
Chronological number of HSCT for this patient?
text
If >1, date of last HSCT before this one
date
If >1, type of last HSCT before this one
text
HSCT part of a planned multiple graft protocol?
boolean
Preparative (conditioning) regimen given?
boolean
Was this intended to be myeloablative?
boolean
Reason
text
Reason
text
Ara-C (cytarabine)
float
Ara-C (cytarabine)
integer
ALG, ATG (ALS, ATS)
float
Unit of dosing
integer
Animal origin
integer
Animal origin
text
Bleomycin
float
Unit of doseing
integer
Busulfan
float
Unit of dosing
integer
Busulfan
integer
BCNU
float
Unit of dosing
integer
Bexar (radiolabelled MoAB)
float
Unit of dosing
integer
CCNU
float
Unit of dosing
integer
Campath (antiCD52)
float
Unit of dosing
integer
Carboplatin
float
Unit of dosing
integer
Cisplatin
float
Unit of dosing
integer
Corticosteroids
float
Unit of dosing
integer
Cyclophosphamide
float
Unit of dosing
integer
Daunorubicin
float
Unit of dosing
integer
Doxorubicin (adriamycine)
float
Unit of dosing
integer
Etoposide (VP16)
float
Unit of dosing
integer
Fludarabine
float
Unit of dosing
integer
Gemtuzumab
float
Unit of dosing
integer
Idarubicin
float
Unit of dosing
integer
Ifosfamide
float
Unit of dosing
integer
Imatinib mesylate
float
Unit of dosing
integer
Melphalan
float
Unit of dosing
integer
Mitoxantrone
float
Unit of dosing
integer
Paclitaxel
float
Unit of dosing
integer
Rituximab (mabthera, antiCD20)
float
Unit of dosing
integer
Teniposide
float
Unit of dosing
integer
Thiotepa
float
Unit of dosing
integer
Zevalin (radiolabelled MoAB)
float
Unit of dosing
integer
Other radiolabelled MoAB
float
Unit of dosing
integer
Other radiolabelled MoAB
text
Other MoAB
float
Unit of dosing
integer
Other
float
Unit of dosing
integer
Total body irradiation
boolean
Total Body Irradiation
text
TLI, TNI, TAI
boolean
TLI, TNI, TAI
text
AFTER HSCT
GvHD prophylaxis or preventive treatment
boolean
GvHD prophylaxis or preventive treatment
integer
GvHD prophylaxis or preventive treatment
text
GvHD prophylaxis or preventive treatment
text
GvHD prophylaxis or preventive treatment
text
Absolute neutrophil count (ANC) recovery (engraftment) (Neutrophils >0.5X109 /L)
integer
Date of last assessment
date
Date of ANC recovery
date
Date of last assessment
date
Maximum grade
integer
ADDITIONAL TREATMENT INCLUDING CELL THERAPY
Cell infusion (CI)
boolean
(can be the same as HSCT date)
date
Type of cell(s): (check all that apply)
integer
Type of cell(s): (check all that apply)
text
Chronological no. of CI for this patient
text
Indication
text
Indication:
text
Infusion count
float
Disease treatment
integer
DISEASE STATUS
Best disease status (response) after HSCT
integer
CR achieved: Date achieved
date
Never in CR: Date assessed
date
Date of last follow up or death
date
Date of last follow up or death
First Relapse or Progression after HSCT
text
Date assessed
date
Date first seen
date
Relapse/progression detected by clinical/haematological method
text
Date assessed
date
Date first seen
date
Relapse/progression detected by cytogenetic method
integer
Date assessed
date
Date first seen
date
Relapse/progression detected by molecular method
integer
Date assessed
date
Date first seen
date
DISEASE PRESENCE/DETECTION AT LAST CONTACT
Was disease detected by clinical/haematological method?:
date
Last date assessed
date
Was disease detected by cytogenetic/FISH method?:
integer
Considered disease relapse/progression
boolean
Last date assessed
date
PATIENT STATUS AT LAST CONTACT
Survival Status
text
Check here if patient lost to follow up
boolean
Cause of Death
integer
HSCT related cause
integer
DATE OF NEXT HSCT
date
COVER PAGE FOR HISTOCOMPATIBILITY REPORTS
EBMT Code (CIC):
text
Hospital
text
Unit:
text
Contact person
text
text
Has the HSCT been registered in the EBMT database ?
boolean
Has the HSCT been registered in the EBMT database ?
text
Hospital Unique Patient Number/ Code
text
Initials
text
Gender
text
Date of Birth
date
Date of HSCT
date
Donor ID
text
PATIENT ETHNIC OR RACIAL ORIGIN
DISEASE OF SECONDARY ORIGIN
THERAPY GIVEN PRIOR TO THIS HSCT
THERAPY GIVEN PRIOR TO THIS HSCT
boolean
THERAPY GIVEN PRIOR TO THIS HSCT
date
Tyrosine kinase receptor antagonist given
boolean
Tyrosine kinase receptor antagonist given
integer
Other agent
text
Were there any clinically significant co-existing disease or organ impairment at time of patient assessment prior to preparative (conditioning) regimen?
boolean
Comorbidity
Treated at any time point in the patient's past history, excluding nonmelanoma skin cancer
integer
Crohn's disease or ulcerative colitis
integer
SLE, RA, polymyositis, mixed CTD, or polymyalgia rheumatica
integer
Requiring continuation of antimicrobial treatment after day 0
integer
Requiring treatment with insulin or oral hypoglycaemics but not diet alone
integer
Serum creatinine > 2 mg/dL or >177 μmol/L, on dialysis, or prior renal transplantation
integer
Chronic hepatitis, bilirubin between Upper Limit Normal (ULN) and 1.5 x the ULN, or AST/ALT between ULN and 2.5 × ULN
integer
Liver cirrhosis, bilirubin greater than 1.5 × ULN, or AST/ALT greater than 2.5 × ULN
integer
Atrial fibrillation or flutter, sick sinus syndrome, or ventricular arrhythmias
integer
Coronary artery disease, congestive heart failure, myocardial infarction, or EF ≤ 50%
integer
Transient ischemic attack or cerebrovascular accident
integer
Except mitral valve prolapse
integer
DLco and/or FEV1 66-80% or dyspnoea on slight activity
integer
DLco and/or FEV1 ≤ 65% or dyspnoea at rest or requiring oxygen
integer
Patients with a body mass index > 35 kg/m2
integer
Peptic ulcer
integer
Depression or anxiety requiring psychiatric consult or treatment
integer
Other Comorbidity
text
GRAFT PERFORMANCE Compulsory for CIBMTR Research centres
GRAFT PERFORMANCE
Platelet reconstitution
text
Date Platelets > 20 x 10 9 /l
date
Compulsory for CIBMTR Research centres. Fill in only if you answered Yes: Planned to the question on Disease treatment under Additional treatment
date
Chemo/drug
boolean
Chemo/drug
integer
Radiotherapy
boolean
HSCT - Minimum Essential Data - A First report - 100 days after HSCT DISEASE CLASSIFICATION SHEET 1
EBMT Centre Identification Code (CIC)
text
Hospital Unique Patient Number/Code (UPN)
text
Date of Initial Diagnosis
date
Classification
AML with recurrent genetic abnormalities
integer
AML not otherwise categorised
integer
Precursor Lymphoid Neoplasms (old ALL)
integer
AML transformed from
integer
Secondary origin
text
Date of this HSCT
date
Status at HSCT
integer
NUMBER
integer
Cytogenetic
integer
Molecular
integer
HSCT - Minimum Essential Data - A First report - 100 days after HSCT DISEASE CLASSIFICATION SHEET 2
EBMT Centre Identification Code (CIC)
text
Hospital Unique Patient Number/Code
text
Date of initial diagnosis
date
Classification
Translocation (9;22)
text
bcr-abl
text
Date of this HSCT
date
Status at HSCT
integer
NUMBER
integer
Haematological
text
Cytogenetic (t[9;22))
integer
Molecular (bcr-abl)
integer
Classification
HSCT - Minimum Essential Data – A First report - 100 days after HSCT DISEASE CLASSIFICATION SHEET 3
EBMT Centre Identification Code (CIC)
text
Hospital Unique Patient Number/Code
text
Date of Initial Diagnosis
date
Mature B-cell Neoplasms
integer
Follicular lymphoma
integer
Mature T-cell & NK-cell Neoplasms
integer
Hodgkin
integer
Date of this HSCT
date
STATUS HSCT
integer
NUMBER
integer
SENSITIVITY TO CHEMOTHERAPY
text
HSCT - Minimum Essential Data - A First report - 100 days after HSCT DISEASE CLASSIFICATION SHEET 4
EBMT Centre Identification Code (CIC)
text
Hospital Unique Patient Number/Code
text
Date of initial diagnosis
date
WHO Classification at diagnosis
integer
FAB Classification at diagnosis
integer
Status at HSCT
integer
NUMBER
text
HSCT - Minimum Essential Data - A First report - 100 days after HSCT DISEASE CLASSIFICATION SHEET 5
EBMT Centre Identification Code (CIC)
text
Hospital Unique Patient Number/Code
text
Date of Initial Diagnosis
date
Classification at diagnosis
integer
Classification at HSCT
integer
Date of this HSCT
date
Treated with chemotherapy
integer
NUMBER
integer
jMML
integer
HSCT - Minimum Essential Data - A First report - 100 days after HSCT DISEASE CLASSIFICATION SHEET 6
EBMT Centre Identification Code (CIC)
text
Hospital Unique Patient Number/Code
text
Date of initial diagnosis
date
Classification at diagnosis
integer
Secondary origin
integer
Date of this HSCT
date
Classification at HSCT
integer
Classification at HSCT
text
Status at HSCT
text
NUMBER (complete for CR or relapse)
integer
HSCT - Minimum Essential Data - A First report - 100 days after HSCT DISEASE CLASSIFICATION SHEET 7
EBMT Centre Identification Code (CIC)
text
Hospital Unique Patient Number/Code
text
Date of Initial Diagnosis
date
Classification
integer
LIGHT CHAIN TYPE
text
SALMON & DURIE STAGE AT DIAGNOSIS
integer
Date of this HSCT
date
Status at HSCT
text
NUMBER (complete for sCR, CR,VGPR, PR or relapse)
integer
BONE MARROW FAILURE SYNDROMES including APLASTIC ANAEMIA (main disease code 7)ISMC
Classification
integer
Acquired Severe Aplastic Anaemia (SAA)
integer
Congenital
integer
Congenital
text
Date of this HSCT
date
HAEMOGLOBINOPATHY Classification
text
HAEMOGLOBINOPATHY Classification
text
Date of this HSCT
date
HSCT - Minimum Essential Data - A First report - 100 days after HSCT DISEASE CLASSIFICATION SHEET 8
EBMT Centre Identification Code (CIC)
text
Hospital Unique Patient Number/Code
text
Date of initial diagnosis
date
Staging at Diagnosis
text
STAGE
integer
CLASSIFICATION
integer
Date of this HSCT
date
Status at HSCT
integer
Complete remission (CR)
integer
Relapse
integer
OTHER MALIGNANCIES (main disease code 5) Classification
text
Classification
text
Date of this HSCT
date
Status at HSCT
text
Complete remission (CR)
integer
NUMBER
integer
SENSITIVITY TO CHEMOTHERAPY
integer
HSCT - Minimum Essential Data - A First report - 100 days after HSCT DISEASE CLASSIFICATION SHEET 9
EBMT Centre Identification Code (CIC)
text
Hospital Unique Patient Number/Code
text
Date of Initial Diagnosis
date
Classification
integer
Date of this HSCT
date
INHERITED DISORDERS OF METABOLISM (main disease code 8) DISMCLFD INHDIS Classification
integer
Date of this HSCT
date
INHERITED DISORDERS OF METABOLISM (main disease code 8)
text
Date of this HSCT
date
PLATELET and OTHER INHERITED DISORDERS (main disease code 8)
integer
Date of this HSCT
date
HISTIOCYTIC DISORDERS (main disease code 9)
text
Date of this HSCT
date
HSCT - Minimum Essential Data - A First report - 100 days after HSCT DISEASE CLASSIFICATION SHEET 10
EBMT Centre Identification Code (CIC)
text
Hospital Unique Patient Number/Code
text
Date of initial diagnosis
date
Name of Referring Physician
text
Address
text
Fax
text
text
AUTOIMMUNE DISORDERS – I (main disease code 10)
integer
Date of this HSCT
date
diffuse cutaneous
boolean
limited cutaneous
boolean
lung parenchyma
boolean
pulmonary hypertension
boolean
systemic hypertension
boolean
renal (biopsy type
boolean
oesophagus
boolean
other GI tract
boolean
Raynaud
boolean
CREST
boolean
diffuse cutaneous
boolean
limited cutaneous
boolean
lung parenchyma
boolean
pulmonary hypertension
boolean
systemic hypertension
boolean
renal (biopsy type
boolean
oesophagus
boolean
other GI tract
boolean
Raynaud
boolean
CREST
boolean
Antibodies studied
integer
Scl 70 positive
text
ACA positive
integer
Date of this HSCT
date
renal
text
renal
boolean
renal
boolean
CNS
text
CNS
boolean
CNS
boolean
PNS
text
PNS
boolean
PNS
boolean
lung
boolean
lung
boolean
serositis
boolean
serositis
boolean
arthritis
boolean
arthritis
boolean
skin
text
skin
boolean
skin
boolean
haematological
text
haematological
boolean
haematological
boolean
vasculitis
text
vasculitis
boolean
vasculitis
boolean
Complement reduced
integer
Antibodies studied
text
HSCT - Minimum Essential Data - A First report - 100 days after HSCT DISEASE CLASSIFICATION SHEET 11
EBMT Centre Identification Code (CIC)
text
Hospital Unique Patient Number/Code
text
Date of Initial Diagnosis
date
Name of Referring Physician
text
Address
text
Fax
text
text
UTOIMMUNE DISORDERS – II (main disease code 10) Classification
integer
Date of this HSCT
date
proximal weakness
boolean
proximal weakness
boolean
generalized weakness (including bulbar)
boolean
generalized weakness (including bulbar)
boolean
pulmonary fibrosis
boolean
pulmonary fibrosis
boolean
vasculitis
text
vasculitis
boolean
vasculitis
boolean
Manifestation with
text
Date of this HSCT
date
SICCA
boolean
SICCA
boolean
exocrine gland swelling
boolean
exocrine gland swelling
boolean
other organ lymphocytic infiltration
boolean
other organ lymphocytic infiltration
boolean
lymphoma, paraproteinaemia
boolean
lymphoma, paraproteinaemia
boolean
other clinical problem
text
Date of this HSCT
date
hrombosis
text
hrombosis
boolean
hrombosis
boolean
CNS
text
CNS
boolean
CNS
boolean
abortion
boolean
abortion
boolean
skin
boolean
skin (livido, vasculitis)
boolean
haematological
text
haematological
boolean
haematological
boolean
Other Involvement/Clinical problem
text
Antibodies studied
integer
Anticardiolipin lgG
integer
Anticardiolipin lgM
integer
Other Antibodies studied
text
Date of this HSCT
date
HSCT - Minimum Essential Data - A First report - 100 days after HSCT DISEASE CLASSIFICATION SHEET 12
EBMT Centre Identification Code (CIC)
text
Hospital Unique Patient Number/Code
text
Date of Initial Diagnosis
date
Name of Referring Physician
text
Address
text
Fax
text
text
Classification VASCULITIS
integer
Date of this HSCT
date
upper respiratory tract
boolean
upper respiratory tract
boolean
pulmonary
boolean
pulmonary
boolean
renal
text
renal
boolean
renal
boolean
skin
boolean
skin
boolean
Other Involvement / Clinical problem
text
Antibodies studied
integer
c-ANCA
integer
Date of this HSCT
date
renal
text
renal
boolean
renal
boolean
mononeuritis multiplex
boolean
mononeuritis multiplex
boolean
pulmonary haemorrhage
boolean
pulmonary haemorrhage
boolean
skin
boolean
skin
boolean
GI tract
boolean
GI tract
boolean
Involvement/Clinical problem
text
Antibodies studied
integer
p-ANCA
integer
c-ANCA
integer
Hepatitis serology
integer
Other vasculitis
integer
Date of this HSCT
date
HSCT - Minimum Essential Data - A First report - 100 days after HSCT DISEASE CLASSIFICATION SHEET 13
EBMT Centre Identification Code (CIC)
text
Hospital Unique Patient Number/Code
text
Date of Initial Diagnosis
date
Name of Referring Physician
text
Address
text
Fax
text
text
AUTOIMMUNE DISORDERS – IV (main disease code 10) ARTHRITIS
integer
Date of this HSCT
date
destructive arthritis
boolean
destructive arthritis
boolean
eye
text
eye
boolean
eye
boolean
pulmonary
boolean
pulmonary
boolean
extra articular
text
extra articular
boolean
extra articular
boolean
Date of this HSCT
date
destructive arthritis
boolean
destructive arthritis
boolean
psoriasis
text
psoriasis
boolean
Date of this HSCT
date
MULTIPLE SCLEROSIS
boolean
Date of this HSCT
date
MULTIPLE SCLEROSIS
integer
OTHER NEUROLOGICAL AUTOIMMUNE DISEASE
text
Other autoimmune neurological disorder
text
Date of this HSCT
date
HAEMATOLOGICAL AUTOIMMUNE DISEASES
integer
other autoimmune cytopenia
text
Date of this HSCT
date
BOWEL DISEASE
text
Other autoimmune bowel disease
text
Date of this HSCT
date
HSCT - Minimum Essential Data - A Follow up report: 1 year post transplant and annually thereafter
PRIMARY DISEASE DIAGNOSIS
text
EBMT Code (CIC)
text
Hospital:
text
Klinik
text
Unit
text
Contact person
text
Date of this Report
date
Patient following national / international study / trial
integer
Name of study / trial
text
Hospital Unique Patient Number/Code
text
Initials
text
Date of Birth
date
Sex
text
Date of the most recent transplant before this follow up
date
Best disease status (response) after transplant
integer
Date achieved
date
Date assessed
date
Date of last follow up or death
date
Chronic Graft Versus Host Disease present during this period
text
Date of diagnosis of cGvHD
date
Date first evidence of cGVHD during this period
date
Maximum extent during this period
integer
Late graft failure (allografts only)
boolean
Did a secondary malignancy, lymphoproliferative or myeloproliferative disorder occur?
boolean
Date of diagnosis
date
Diagnosis:
text
ADDITIONAL DISEASE TREATMENT INCLUDING CELL THERAPY
boolean
ADDITIONAL DISEASE TREATMENT INCLUDING CELL THERAPY
date
Additional cell infusion (not HSCT or auto re-infusion)
boolean
Other treatment of disease
integer
First Relapse or Progression after HSCT
text
Date assessed
date
Date first seen
date
Relapse/progression detected by clinical/haematological method
integer
Date assessed
date
Date first seen
date
Relapse/progression detected by cytogenetic method
integer
Date assessed
boolean
Date first seen
date
Relapse/progression detected by molecular method
integer
Date assessed
date
Date first seen
date
Last disease status (record the most recent status and date for each method, relating to the initial disease for which HSCT was given)
integer
Last date assessed
date
Was disease detected by cytogenetic/FISH method?:
boolean
Considered disease relapse/progression
boolean
Last date assessed
date
Was disease detected by molecular method?
integer
Considered disease relapse/progression
boolean
Last date assessed
date
Has patient or partner become pregnant after this transplant?
integer
Survival Status
integer
Check here if patient lost to follow up
boolean
Cause of Death
integer
HSCT Related Cause
text
HSCT Related Cause
text
HSCT - Minimum Essential Data - A Follow up report: Annual follow up CELL INFUSION (CI) SHEET
EBMT Centre Identification Code (CIC)
text
Hospital Unique Patient Number/Code
text
Date of first infusion
date
Disease status before this CI
integer
Date of first infusion
date
Disease status before this CI
integer
Cell infusion (CI) regimen
text
Cell infusion (CI) regimen
text
Chronological no. of CI for this patient
text
Indication
integer
Infusion count
float
Maximum Grade
integer