ID

12558

Beschrijving

The European Society for Blood and Marrow Transplantation maintains a huge registry and delivers data collection forms. The original forms for submitting data to the EBMT can be found under: http://www.ebmt.org/Contents/Data-Management/Registrystructure/MED-ABdatacollectionforms/Pages/MED-AB-data-collection-forms.aspx#HSCTMedB This ODM form is derived from the AML-disease specific form of the section MED-B. http://www.ebmt.org/Contents/Data-Management/Registrystructure/MED-ABdatacollectionforms/Documents/05AL.pdf

Link

http://www.ebmt.org/Contents/Data-Management/Registrystructure/MED-ABdatacollectionforms/Pages/MED-AB-data-collection-forms.aspx#HSCTMedB

Trefwoorden

Versies (4)
  1. 18-11-15 18-11-15 -
  2. 30-11-15 30-11-15 -
  3. 11-02-16 11-02-16 -
  4. 20-09-21 20-09-21 -
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30 november 2015

DOI

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Licentie

Creative Commons BY-NC 3.0
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Acute Leukaemia AML EBMT HSCT Registry MED-B Disease Specific Form

Engels

Acute Leukaemia AML EBMT HSCT Registry MED-B Disease Specific Form

1 Formulieren  
Team
Beschrijving

Team

Alias
UMLS CUI-1
C0019994
EBMT Centre Identification Code (CIC)
Beschrijving

EBMT Centre Identification Code (CIC)

Datatype

text

Alias
UMLS CUI [1]
C0802049
Hospital
Beschrijving

Hospital

Datatype

text

Alias
UMLS CUI [1]
C0019994
Unit
Beschrijving

UnitDepartment

Datatype

text

Alias
UMLS CUI [1]
C1704729
Contact Person
Beschrijving

Contact Person

Datatype

text

Alias
UMLS CUI [1]
C0337611
Telephone
Beschrijving

Telephone

Datatype

integer

Alias
UMLS CUI [1]
C1515258
Fax
Beschrijving

Fax number

Datatype

integer

Alias
UMLS CUI [1]
C1549619
E-mail
Beschrijving

E-mail

Datatype

text

Alias
UMLS CUI [1]
C1705961
Report date
Beschrijving

Report date

Datatype

date

Maateenheden
  • yyyy/mm/dd
Alias
UMLS CUI [1]
C1302584
yyyy/mm/dd
Patient following national / international study / trial
Beschrijving

Patient in Trial

Datatype

integer

Alias
UMLS CUI [1]
C1997894
Name of study / trial
Beschrijving

Name of study / trial

Datatype

text

Alias
UMLS CUI [1]
C0008976
Patient
Beschrijving

Patient

Alias
UMLS CUI-1
C0030705
Unique Identification Code (UIC)
Beschrijving

Identification code

Datatype

text

Alias
UMLS CUI [1]
C1827636
Hospital Unique Patient Number or Code
Beschrijving

Patient code

Datatype

text

Alias
UMLS CUI [1]
C1827636
Initials (first name(s) - surname(s))
Beschrijving

Initials (first name(s) - surname(s))

Datatype

text

Alias
UMLS CUI [1]
C2986440
Patient date of birth
Beschrijving

Patient date of birth

Datatype

date

Maateenheden
  • yyyy/mm/dd
Alias
UMLS CUI [1]
C0421451
yyyy/mm/dd
Sex
Beschrijving

Sex

Datatype

text

Alias
UMLS CUI [1]
C0079399
AB0 Group
Beschrijving

AB0 Group

Datatype

text

Alias
UMLS CUI [1]
C0000778
Rh factor
Beschrijving

Rh factor

Datatype

text

Alias
UMLS CUI [1]
C0035403
Disease
Beschrijving

Disease

Alias
UMLS CUI-1
C0012634
Date of diagnosis
Beschrijving

Date of diagnosis

Datatype

date

Maateenheden
  • yyyy/mm/dd
Alias
UMLS CUI [1]
C2316983
yyyy/mm/dd
Primary disease diagnosis
Beschrijving

Primary disease diagnosis

Datatype

integer

Alias
UMLS CUI [1]
C0011900
Other diagnosis, specify:
Beschrijving

Specify

Datatype

text

Alias
UMLS CUI [1]
C1521902
Initial Diagnosis
Beschrijving

Initial Diagnosis

Alias
UMLS CUI-1
C0011900
Has the information requested in this section been submitted with a previous HSCT registration for this patient?
Beschrijving

SubmittedPreviously

Datatype

integer

Diagnosis
Beschrijving

Diagnosis

Datatype

integer

Alias
UMLS CUI [1]
C0011900
Other, specify:
Beschrijving

Specify

Datatype

text

Alias
UMLS CUI [1]
C1521902
WHO Classification at Diagnosis of de novo AML Acute myeloid leukaemia with recurrent genetic abnormalities:
Beschrijving

WHO Classification AML

Datatype

integer

Alias
UMLS CUI [1]
C1301142
Acute myeloid leukaemia, not otherwise categorized, classify as
Beschrijving

Acute myeloid leukaemia, not otherwise categorized, classify as

Datatype

integer

Alias
UMLS CUI [1]
C1533066
Specify
Beschrijving

Specify

Datatype

text

Alias
UMLS CUI [1]
C1521902
WHO Classification at diagnosis of de novo Precursor Lymphoid Neoplasms (old ALL)
Beschrijving

WHO Classification at diagnosis of de novo Precursor Lymphoid Neoplasms (old ALL)

Datatype

integer

Alias
UMLS CUI [1]
C1301142
UMLS CUI [2]
C1335469
UMLS CUI [3]
C0023449
Specify
Beschrijving

Specify

Datatype

text

Alias
UMLS CUI [1]
C1521902
Secondary origin (If the answer to this question is “Yes” for any reason, do not complete this form; instead complete the MYELODYSPLASTIC SYNDROME or MDS+MPS or SECONDARY ACUTE LEUKAEMIA form)
Beschrijving

Secondary origin

Datatype

integer

Alias
UMLS CUI [1]
C3266877
Cytgenetics
Beschrijving

Cytgenetics

Alias
UMLS CUI-1
C0010802
Chromosome analysis
Beschrijving

Chromosome analysis

Datatype

integer

Alias
UMLS CUI [1]
C0200867
If abnormal: Are there 3 or more abnormalities (complex kariotype)?
Beschrijving

If abnormal: Are there 3 or more abnormalities (complex kariotype)?

Datatype

integer

Alias
UMLS CUI [1]
C3273253
If done: number of metaphases with abnormalites
Beschrijving

If done: number of metaphases with abnormalites

Datatype

float

Alias
UMLS CUI [1,1]
C1621812
UMLS CUI [1,2]
C0008625
UMLS CUI [1,3]
C0750480
number of metaphases examined
Beschrijving

number of metaphases examined

Datatype

float

Alias
UMLS CUI [1]
C1621812
Indicate which abnormalities found
Beschrijving

Indicate which abnormalities found

Datatype

integer

Alias
UMLS CUI [1]
C0008625
If hypodiploid/hyperdiploid: number of chromosomes
Beschrijving

Number of chromosomes

Datatype

integer

Alias
UMLS CUI [1]
C1953343
Other or associated abnormalities (specify, including whether absent or present)
Beschrijving

Other or associated abnormalities (specify, including whether absent or present)

Datatype

text

Alias
UMLS CUI [1]
C0008625
Molecular Biology
Beschrijving

Molecular Biology

Alias
UMLS CUI-1
C0026376
Molecular markers
Beschrijving

Molecular markers

Datatype

integer

Alias
UMLS CUI [1]
C0005516
BCR-ABL
Beschrijving

BCR-ABL

Datatype

integer

Alias
UMLS CUI [1]
C1835417
PML-RAR
Beschrijving

PML-RAR

Datatype

integer

AML1-ETO
Beschrijving

AML1-ETO

Datatype

integer

Alias
UMLS CUI [1]
C0665119
FLT3-ITD
Beschrijving

FLT3-ITD

Datatype

integer

Alias
UMLS CUI [1]
C2348499
CEBPA mutation
Beschrijving

CEBPA mutation

Datatype

integer

Alias
UMLS CUI [1]
C1511473
NPM1 mutation
Beschrijving

NPM1 mutation

Datatype

integer

Alias
UMLS CUI [1]
C2826175
MLL-PTD
Beschrijving

MLL-PTD

Datatype

integer

Alias
UMLS CUI [1]
C3829001
Other
Beschrijving

Other

Datatype

integer

Alias
UMLS CUI [1]
C0205394
Specify
Beschrijving

Specify

Datatype

text

Alias
UMLS CUI [1]
C1521902
White blood cell count at diagnosis
Beschrijving

WBC

Datatype

float

Maateenheden
  • 10^9/l
Alias
UMLS CUI [1]
C0023508
10^9/l
WBC not available/unknown
Beschrijving

WBC not available/unknown

Datatype

integer

Involvement at Diagnosis
Beschrijving

Involvement at Diagnosis

Alias
UMLS CUI-1
C0027646
Bone marrow
Beschrijving

BM

Datatype

integer

Metastases CNS
Beschrijving

CNS

Datatype

integer

Alias
UMLS CUI [1]
C0686377
Testis/ovary
Beschrijving

Testis/ovary

Datatype

integer

Alias
UMLS CUI [1]
C0039597
UMLS CUI [2]
C0029939
Chloroma
Beschrijving

Chloroma

Datatype

integer

Alias
UMLS CUI [1]
C0152276
Other
Beschrijving

Other

Datatype

integer

Alias
UMLS CUI [1]
C0205394
Type of HSCT
Beschrijving

Type of HSCT

Alias
UMLS CUI-1
C0472699
HSCT
Beschrijving

HSCT

Datatype

integer

Alias
UMLS CUI [1]
C0472699
Treatment and Status of Disease at Stem Cell Collection
Beschrijving

Treatment and Status of Disease at Stem Cell Collection

Alias
UMLS CUI-1
C0457411
Date of Collection
Beschrijving

Date of Collection

Datatype

date

Maateenheden
  • yyyy/mm/dd
Alias
UMLS CUI [1,1]
C3827940
UMLS CUI [1,2]
C0011008
yyyy/mm/dd
Number of chemotherapy course(s) from last CR to stem cell collection (fill in only if patient had a CR prior to this HSCT )
Beschrijving

Treatment Number Chemotherapy

Datatype

float

Alias
UMLS CUI [1]
C0392920
UMLS CUI [2,1]
C1302181
UMLS CUI [2,2]
C0750480
Number of chemotherapy course(s) from collection to HSCT
Beschrijving

Number of chemotherapy course(s) from collection to HSCT

Datatype

text

Alias
UMLS CUI [1]
C0392920
Disease Hematological Status
Beschrijving

Disease Hematological Status

Datatype

integer

Alias
UMLS CUI [1]
C1302181
Complete cytogenetic remission (fill in only if cytogenetic abnormality/ies detected at diagnosis)
Beschrijving

Complete cytogenetic remission

Datatype

integer

Alias
UMLS CUI [1,1]
C0010802
UMLS CUI [1,2]
C0677874
Complete molecular remission (fill in only if molecular abnormality/ies detected at diagnosis)
Beschrijving

Complete molecular remission

Datatype

integer

Alias
UMLS CUI [1,1]
C0026376
UMLS CUI [1,2]
C0677874
Status of Disease at HSCT
Beschrijving

Status of Disease at HSCT

Alias
UMLS CUI-1
C1704632
UMLS CUI-2
C0472699
Hematological status (considering number of blasts in bone marrow)
Beschrijving

Hematological status

Datatype

integer

Alias
UMLS CUI [1]
C1302181
Complete cytogenetic remission (fill in only if cytogenetic abnormality/ies detected at diagnosis)
Beschrijving

Complete cytogenetic remission

Datatype

integer

Alias
UMLS CUI [1,1]
C0010802
UMLS CUI [1,2]
C0677874
Complete molecular remission (fill in only if molecular abnormality/ies detected at diagnosis)
Beschrijving

Complete molecular remission

Datatype

integer

Alias
UMLS CUI [1,1]
C0026376
UMLS CUI [1,2]
C0677874
Additional Treatment Post-HSCT
Beschrijving

Additional Treatment Post-HSCT

Alias
UMLS CUI-1
C1706712
Additional disease treatment
Beschrijving

Additional disease treatment

Datatype

integer

Alias
UMLS CUI [1]
C1706712
Best disease response at 100 days post-HSCT
Beschrijving

Best disease response at 100 days post-HSCT

Alias
UMLS CUI-1
C1704632
Best response at 100 days after HSCT
Beschrijving

Best response at 100 days after HSCT

Datatype

integer

Alias
UMLS CUI [1]
C1704632
If complete response: date of CR
Beschrijving

CR Date

Datatype

date

Maateenheden
  • yyyy/mm/dd
Alias
UMLS CUI [1,1]
C0677874
UMLS CUI [1,2]
C0011008
yyyy/mm/dd
Forms to be filled in
Beschrijving

Forms to be filled in

Alias
UMLS CUI-1
C2985594
AUTOgraft, proceed to Autograft form
Beschrijving

AUTOgraft, proceed to Autograft form

Datatype

text

ALLOgraft or Syngeneic graft, proceed to Allograft form
Beschrijving

ALLOgraft or Syngeneic graft, proceed to Allograft form

Datatype

text

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Acute Leukaemia AML EBMT HSCT Registry MED-B Disease Specific Form

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Team
C0019994 (UMLS CUI-1)
EBMT Centre Identification Code (CIC)
Item
text
C0802049 (UMLS CUI [1])
Hospital
Item
text
C0019994 (UMLS CUI [1])
UnitDepartment
Item
Unit
text
C1704729 (UMLS CUI [1])
Contact Person
Item
text
C0337611 (UMLS CUI [1])
Telephone
Item
integer
C1515258 (UMLS CUI [1])
Fax number
Item
Fax
integer
C1549619 (UMLS CUI [1])
E-mail
Item
text
C1705961 (UMLS CUI [1])
Report date
Item
date
C1302584 (UMLS CUI [1])
Item
Patient following national / international study / trial
integer
C1997894 (UMLS CUI [1])
Patient in Trial
Code List
Patient following national / international study / trial
CL Item
No (1)
CL Item
Yes (2)
CL Item
Not evaluated (3)
CL Item
Unknown (4)
Name of study / trial
Item
text
C0008976 (UMLS CUI [1])
Item Group
C0030705 (UMLS CUI-1)
Identification code
Item
Unique Identification Code (UIC)
text
C1827636 (UMLS CUI [1])
Patient code
Item
Hospital Unique Patient Number or Code
text
C1827636 (UMLS CUI [1])
Initials (first name(s) - surname(s))
Item
text
C2986440 (UMLS CUI [1])
Patient date of birth
Item
date
C0421451 (UMLS CUI [1])
Item
text
C0079399 (UMLS CUI [1])
Sex
Code List
Sex
CL Item
Male (Male)
CL Item
Female (Female)
AB0 Group
Item
text
C0000778 (UMLS CUI [1])
Item
text
C0035403 (UMLS CUI [1])
Rh factor
Code List
Rh factor
CL Item
Absent (Absent)
CL Item
Present (Present)
CL Item
Not evaluated (Not evaluated)
Item Group
C0012634 (UMLS CUI-1)
Date of diagnosis
Item
date
C2316983 (UMLS CUI [1])
Item
Primary disease diagnosis
integer
C0011900 (UMLS CUI [1])
Primary disease diagnosis
Code List
Primary disease diagnosis
CL Item
Acute Leukaemia (1)
C0085669 (UMLS CUI-1)
CL Item
Myelogenous (AML) (2)
C0023467 (UMLS CUI-1)
CL Item
Lymphoblastic (ALL) (3)
C0023449 (UMLS CUI-1)
CL Item
Secondary Acute Leukaemia(do not use if transformed from MDS/MPN) (4)
C0280449 (UMLS CUI-1)
CL Item
Chronic Leukaemia (5)
C1279296 (UMLS CUI-1)
CL Item
Chronic Myeloid Leukaemia (CML) (6)
C0023473 (UMLS CUI-1)
CL Item
Chronic Lymphocytic Leukaemia (7)
C0023434 (UMLS CUI-1)
CL Item
Lymphoma (8)
C0024299 (UMLS CUI-1)
CL Item
Non Hodgkin (9)
C0024305 (UMLS CUI-1)
CL Item
Hodgkin's Disease (10)
C0019829 (UMLS CUI-1)
CL Item
Myeloma /Plasma cell disorder (11)
C0026764 (UMLS CUI-1)
C0023484 (UMLS CUI-2)
CL Item
Solid Tumour (12)
C0280100 (UMLS CUI-1)
CL Item
Myelodysplastic syndromes (13)
C0280450 (UMLS CUI-1)
CL Item
MDS (14)
C3463824 (UMLS CUI-1)
CL Item
MD/MPN (15)
C0027022 (UMLS CUI-1)
C1292778 (UMLS CUI-2)
CL Item
Myeloproliferative neoplasm (16)
C1333046 (UMLS CUI-1)
CL Item
Bone marrow failure including Aplastic anaemia (17)
C2931245 (UMLS CUI-1)
C0002874 (UMLS CUI-2)
CL Item
Inherited disorders (18)
C0019247 (UMLS CUI-1)
CL Item
Primary immune deficiencies (19)
C0398686 (UMLS CUI-1)
CL Item
Metabolic disorders (20)
C0025517 (UMLS CUI-1)
CL Item
Histiocytic disorders (21)
C0398597 (UMLS CUI-1)
CL Item
Autoimmune disease (22)
C0004364 (UMLS CUI-1)
CL Item
Juvenile Idiopathic Arthritis (23)
C1444841 (UMLS CUI-1)
CL Item
Multiple Sclerosis (24)
C0026769 (UMLS CUI-1)
CL Item
Systemic Lupus (25)
C0024141 (UMLS CUI-1)
CL Item
Systemic Sclerosis (26)
C0036421 (UMLS CUI-1)
CL Item
Haemoglobinopathy (27)
C0019045 (UMLS CUI-1)
CL Item
Other diagnosis (28)
C0205394 (UMLS CUI-1)
Specify
Item
Other diagnosis, specify:
text
C1521902 (UMLS CUI [1])
Item Group
C0011900 (UMLS CUI-1)
Item
Has the information requested in this section been submitted with a previous HSCT registration for this patient?
integer
SubmittedPreviously
Code List
Has the information requested in this section been submitted with a previous HSCT registration for this patient?
CL Item
Yes: go to page 5, Type of HSCT (1)
CL Item
No: proceed with this section (2)
Item
integer
C0011900 (UMLS CUI [1])
Diagnosis
Code List
Diagnosis
CL Item
Acute Myelogenous Leukaemia (AML)(non-lymphoblastic) → Fill in subclassification below (1)
C0023467 (UMLS CUI-1)
CL Item
Precursor lymphoid neoplasm (old ALL) → Fill in subclassification in next page (2)
C0023449 (UMLS CUI-1)
CL Item
Acute Undifferentiated Leukaemia (3)
C0280141 (UMLS CUI-1)
CL Item
Mixed phenotype leukaemia NOS (4)
C2826025 (UMLS CUI-1)
CL Item
Mixed phenotype B/myeloid, NOS (5)
C3472616 (UMLS CUI-1)
CL Item
Mixed phenotype T/myeloid, NOS (6)
C2826055 (UMLS CUI-1)
CL Item
Natural killer (NK)- cell lymphoblastic leukaemia/lymphoma (7)
C2826059 (UMLS CUI-1)
CL Item
Other, specify: (8)
C0205394 (UMLS CUI-1)
Specify
Item
Other, specify:
text
C1521902 (UMLS CUI [1])
Item
WHO Classification at Diagnosis of de novo AML Acute myeloid leukaemia with recurrent genetic abnormalities:
integer
C1301142 (UMLS CUI [1])
WHO Classification AML
Code List
WHO Classification at Diagnosis of de novo AML Acute myeloid leukaemia with recurrent genetic abnormalities:
CL Item
AML with t(8;21)(q22;q22); RUNX1-RUNX1T1 (1)
C1515794 (UMLS CUI-1)
C1851466 (UMLS CUI-2)
CL Item
AML with inv(16)(p13.1;q22) or t(16;16)(p13.1;q22); CBFB-MYH11 (2)
C3897145 (UMLS CUI-1)
C2828339 (UMLS CUI-2)
C3276534 (UMLS CUI-3)
CL Item
Acute promyelocytic leukaemia with t(15;17)(q22;q12); PML/RARA (3)
C1515724 (UMLS CUI-1)
C3887967 (UMLS CUI-2)
CL Item
AML with t(9;11) (p22;q23); MLLT 3-MLL (4)
C1515800 (UMLS CUI-1)
CL Item
AML with myelodysplasia related changes (with multilineage dysplasia; w/o MDS or MDS/MPN antecedents) (5)
C2825139 (UMLS CUI-1)
CL Item
AML with t(6;9) (p23;q24); DEK-NUP214 (6)
C1507070 (UMLS CUI-1)
CL Item
AML with inv(3) (q21;q26.2) or t(3;3) (q21;q26.2); RPN1-EVI1 (7)
C2826172 (UMLS CUI-1)
CL Item
AML (megakaryoblastic) with t(1;22) (p13;q13); RBM15-MKL1 (8)
C2826173 (UMLS CUI-1)
Acute myeloid leukaemia, not otherwise categorized, classify as
Code List
Acute myeloid leukaemia, not otherwise categorized, classify as
CL Item
AML with minimal differentiation (FAB M0) (1)
C0457327 (UMLS CUI-1)
CL Item
AML without maturation (FAB M1) (2)
C0457328 (UMLS CUI-1)
CL Item
AML with maturation (FAB M2) (3)
C0457352 (UMLS CUI-1)
CL Item
Acute myelomonocytic leukaemia (FAB M4) (4)
C0457331 (UMLS CUI-1)
CL Item
Acute monoblastic and monocytic leukaemia (FAB M5) (5)
C0457333 (UMLS CUI-1)
CL Item
Acute erythroid leukaemia (FAB M6) (6)
C0457336 (UMLS CUI-1)
CL Item
Acute megakaryoblastic leukaemia (FAB M7) (7)
C0457337 (UMLS CUI-1)
CL Item
Acute basophilic leukaemia (8)
C0023437 (UMLS CUI-1)
CL Item
Acute panmyelosis with myelofibrosis (9)
C0334674 (UMLS CUI-1)
CL Item
Myeloid sarcoma (Granulocytic sarcoma) (10)
C0152276 (UMLS CUI-1)
CL Item
Myeloid proliferations related to Down syndrome (11)
C2826104 (UMLS CUI-1)
CL Item
Blastic plasmacytoid dendritic cell neoplasm (BPDCN) (12)
C1301363 (UMLS CUI-1)
CL Item
Acute myeloid leukaemia not otherwise specified or other (13)
C0023467 (UMLS CUI-1)
C1518425 (UMLS CUI-2)
C0205394 (UMLS CUI-3)
Specify
Item
text
C1521902 (UMLS CUI [1])
Item
WHO Classification at diagnosis of de novo Precursor Lymphoid Neoplasms (old ALL)
integer
C1301142 (UMLS CUI [1])
C1335469 (UMLS CUI [2])
C0023449 (UMLS CUI [3])
WHO Classification at diagnosis of de novo Precursor Lymphoid Neoplasms (old ALL)
Code List
WHO Classification at diagnosis of de novo Precursor Lymphoid Neoplasms (old ALL)
CL Item
B lymphoblastic leukaemia/lymphoma NOS (old Precursor B-cell ALL) (1)
C0861294 (UMLS CUI-1)
CL Item
with t(9;22)(q34;q11.2); BCR-ABL1 (2)
C1709527 (UMLS CUI-1)
CL Item
with t(v;11q23); MLL rearranged (3)
C2698308 (UMLS CUI-1)
CL Item
with t(12;21)(p13;q22); TEL-AML1 (ETV-RUNX1) (4)
C2698305 (UMLS CUI-1)
CL Item
with hyperdiploidy (5)
C2698311 (UMLS CUI-1)
CL Item
with hypodiploidy (6)
C2698312 (UMLS CUI-1)
CL Item
with t(5;14)(q31;q32); IL3-IGH (7)
C2698307 (UMLS CUI-1)
CL Item
with t(1;19)(q23;p13.3); E2A-PBX1 (8)
C2698306 (UMLS CUI-1)
CL Item
T lymphoblastic leukaemia/lymphoma (old Precursor T-cell ALL) (9)
C1961099 (UMLS CUI-1)
CL Item
lymphoblastic leukaemia/lymphoma not otherwise specifed or other (10)
C3472618 (UMLS CUI-1)
C0205394 (UMLS CUI-2)
Specify
Item
text
C1521902 (UMLS CUI [1])
Item
Secondary origin (If the answer to this question is “Yes” for any reason, do not complete this form; instead complete the MYELODYSPLASTIC SYNDROME or MDS+MPS or SECONDARY ACUTE LEUKAEMIA form)
integer
C3266877 (UMLS CUI [1])
Secondary origin
Code List
Secondary origin (If the answer to this question is “Yes” for any reason, do not complete this form; instead complete the MYELODYSPLASTIC SYNDROME or MDS+MPS or SECONDARY ACUTE LEUKAEMIA form)
CL Item
No (1)
CL Item
Yes, evolution of MDS  (2)
C1332153 (UMLS CUI-1)
CL Item
Yes, disease related to prior exposure to therapeutic drugs or radiation (treatment for previous malignancies) (3)
C0522757 (UMLS CUI-1)
C1384668 (UMLS CUI-3)
C0920425 (UMLS CUI-5)
Item Group
C0010802 (UMLS CUI-1)
Item
integer
C0200867 (UMLS CUI [1])
Chromosome analysis
Code List
Chromosome analysis
CL Item
Not done or failed (1)
CL Item
Done: normal  (2)
C0428095 (UMLS CUI-1)
CL Item
Done: abnormal  (3)
C0476431 (UMLS CUI-1)
CL Item
Unknown (4)
If abnormal: Are there 3 or more abnormalities (complex kariotype)?
Code List
If abnormal: Are there 3 or more abnormalities (complex kariotype)?
CL Item
No (1)
C1298908 (UMLS CUI-1)
CL Item
Yes (2)
C1705108 (UMLS CUI-1)
CL Item
Not evaluated (3)
C3846720 (UMLS CUI-1)
CL Item
Unknown (4)
C0439673 (UMLS CUI-1)
If done: number of metaphases with abnormalites
Item
float
C1621812 (UMLS CUI [1,1])
C0008625 (UMLS CUI [1,2])
C0750480 (UMLS CUI [1,3])
number of metaphases examined
Item
float
C1621812 (UMLS CUI [1])
Item
integer
C0008625 (UMLS CUI [1])
Indicate which abnormalities found
Code List
Indicate which abnormalities found
CL Item
hypodiploid (<46) absent (1)
C0333691 (UMLS CUI-1)
CL Item
hypodiploid (<46) present (2)
C0333691 (UMLS CUI-1)
CL Item
hyperdiploid (>46 ) absent (3)
C1305143 (UMLS CUI-1)
CL Item
hyperdiploid (>46 ) present (4)
C1305143 (UMLS CUI-1)
CL Item
pseudodiploid absent (5)
C2656342 (UMLS CUI-1)
CL Item
pseudodiploid present (6)
C2656342 (UMLS CUI-1)
CL Item
t(9;22) absent (7)
C3897138 (UMLS CUI-1)
CL Item
t(9;22) present (8)
C3897138 (UMLS CUI-1)
CL Item
t(4;11) absent (9)
C1515769 (UMLS CUI-1)
CL Item
t(4;11) present (10)
C1515769 (UMLS CUI-1)
CL Item
inv (16) absent (11)
C3897144 (UMLS CUI-1)
CL Item
inv (16) present (12)
C3897144 (UMLS CUI-1)
CL Item
t(15;17) absent (13)
C1515724 (UMLS CUI-1)
CL Item
t(15;17) present (14)
C1515724 (UMLS CUI-1)
CL Item
t(8;21) absent (15)
C3897139 (UMLS CUI-1)
CL Item
t(8;21) present (16)
C3897139 (UMLS CUI-1)
CL Item
abn 5 absent (17)
C0265408 (UMLS CUI-1)
CL Item
abn 5 present (18)
C0265408 (UMLS CUI-1)
CL Item
other abn 11q absent (19)
C0796366 (UMLS CUI-1)
CL Item
other abn 11q present (20)
C0796366 (UMLS CUI-1)
CL Item
t(12;21) absent (21)
C1515717 (UMLS CUI-1)
CL Item
t(12;21) present (22)
C1515717 (UMLS CUI-1)
CL Item
t(1;19) absent (23)
C1515739 (UMLS CUI-1)
CL Item
t(1;19) present (24)
C1515739 (UMLS CUI-1)
CL Item
trisomy 8 absent (25)
C0432412 (UMLS CUI-1)
CL Item
trisomy 8 present (26)
C0432412 (UMLS CUI-1)
CL Item
monosomy 7 absent (27)
C1513483 (UMLS CUI-1)
CL Item
monosomy 7 present (28)
C1513483 (UMLS CUI-1)
CL Item
other abn 7 absent (29)
C0265413 (UMLS CUI-1)
CL Item
other abn 7 present (30)
C0265413 (UMLS CUI-1)
CL Item
Other or associated abnormalities (specify, including whether absent or present) (31)
Number of chromosomes
Item
If hypodiploid/hyperdiploid: number of chromosomes
integer
C1953343 (UMLS CUI [1])
Other or associated abnormalities (specify, including whether absent or present)
Item
text
C0008625 (UMLS CUI [1])
Item Group
C0026376 (UMLS CUI-1)
Item
Molecular markers
integer
C0005516 (UMLS CUI [1])
Molecular markers
Code List
Molecular markers
CL Item
Evaluated: Absent  (1)
C0332197 (UMLS CUI-1)
CL Item
Evaluated: Present (2)
C0150312 (UMLS CUI-1)
CL Item
Not evaluated (3)
C3846720 (UMLS CUI-1)
CL Item
unknown (4)
C0439673 (UMLS CUI-1)
Item
BCR-ABL
integer
C1835417 (UMLS CUI [1])
BCR-ABL
Code List
BCR-ABL
CL Item
Absent (1)
C0332197 (UMLS CUI-1)
CL Item
Present (2)
C0150312 (UMLS CUI-1)
CL Item
Not evaluated (3)
C3846720 (UMLS CUI-1)
CL Item
unknown (4)
C0439673 (UMLS CUI-1)
Item
integer
BCR-ABL
Code List
PML-RAR
CL Item
Absent (1)
C0332197 (UMLS CUI-1)
CL Item
Present (2)
C0150312 (UMLS CUI-1)
CL Item
Not evaluated (3)
C3846720 (UMLS CUI-1)
CL Item
unknown (4)
C0439673 (UMLS CUI-1)
Item
integer
C0665119 (UMLS CUI [1])
BCR-ABL
Code List
AML1-ETO
CL Item
Absent (1)
C0332197 (UMLS CUI-1)
CL Item
Present (2)
C0150312 (UMLS CUI-1)
CL Item
Not evaluated (3)
C3846720 (UMLS CUI-1)
CL Item
unknown (4)
C0439673 (UMLS CUI-1)
Item
integer
C2348499 (UMLS CUI [1])
BCR-ABL
Code List
FLT3-ITD
CL Item
Absent (1)
C0332197 (UMLS CUI-1)
CL Item
Present (2)
C0150312 (UMLS CUI-1)
CL Item
Not evaluated (3)
C3846720 (UMLS CUI-1)
CL Item
unknown (4)
C0439673 (UMLS CUI-1)
Item
integer
C1511473 (UMLS CUI [1])
BCR-ABL
Code List
CEBPA mutation
CL Item
Absent (1)
C0332197 (UMLS CUI-1)
CL Item
Present (2)
C0150312 (UMLS CUI-1)
CL Item
Not evaluated (3)
C3846720 (UMLS CUI-1)
CL Item
unknown (4)
C0439673 (UMLS CUI-1)
Item
integer
C2826175 (UMLS CUI [1])
BCR-ABL
Code List
NPM1 mutation
CL Item
Absent (1)
C0332197 (UMLS CUI-1)
CL Item
Present (2)
C0150312 (UMLS CUI-1)
CL Item
Not evaluated (3)
C3846720 (UMLS CUI-1)
CL Item
unknown (4)
C0439673 (UMLS CUI-1)
Item
integer
C3829001 (UMLS CUI [1])
BCR-ABL
Code List
MLL-PTD
CL Item
Absent (1)
C0332197 (UMLS CUI-1)
CL Item
Present (2)
C0150312 (UMLS CUI-1)
CL Item
Not evaluated (3)
C3846720 (UMLS CUI-1)
CL Item
unknown (4)
C0439673 (UMLS CUI-1)
Item
integer
C0205394 (UMLS CUI [1])
BCR-ABL
Code List
Other
CL Item
Absent (1)
C0332197 (UMLS CUI-1)
CL Item
Present (2)
C0150312 (UMLS CUI-1)
CL Item
Not evaluated (3)
C3846720 (UMLS CUI-1)
CL Item
unknown (4)
C0439673 (UMLS CUI-1)
Specify
Item
text
C1521902 (UMLS CUI [1])
WBC
Item
White blood cell count at diagnosis
float
C0023508 (UMLS CUI [1])
WBC not available/unknown
Code List
WBC not available/unknown
CL Item
not available (1)
C1548671 (UMLS CUI-1)
CL Item
unknown (2)
C0439673 (UMLS CUI-1)
Item Group
C0027646 (UMLS CUI-1)
Item
Bone marrow
integer
If abnormal: Are there 3 or more abnormalities (complex kariotype)?
Code List
Bone marrow
CL Item
No (1)
C1298908 (UMLS CUI-1)
CL Item
Yes (2)
C1705108 (UMLS CUI-1)
CL Item
Not evaluated (3)
C3846720 (UMLS CUI-1)
CL Item
Unknown (4)
C0439673 (UMLS CUI-1)
Item
Metastases CNS
integer
C0686377 (UMLS CUI [1])
If abnormal: Are there 3 or more abnormalities (complex kariotype)?
Code List
Metastases CNS
CL Item
No (1)
C1298908 (UMLS CUI-1)
CL Item
Yes (2)
C1705108 (UMLS CUI-1)
CL Item
Not evaluated (3)
C3846720 (UMLS CUI-1)
CL Item
Unknown (4)
C0439673 (UMLS CUI-1)
Item
Testis/ovary
integer
C0039597 (UMLS CUI [1])
C0029939 (UMLS CUI [2])
If abnormal: Are there 3 or more abnormalities (complex kariotype)?
Code List
Testis/ovary
CL Item
No (1)
C1298908 (UMLS CUI-1)
CL Item
Yes (2)
C1705108 (UMLS CUI-1)
CL Item
Not evaluated (3)
C3846720 (UMLS CUI-1)
CL Item
Unknown (4)
C0439673 (UMLS CUI-1)
Item
Chloroma
integer
C0152276 (UMLS CUI [1])
If abnormal: Are there 3 or more abnormalities (complex kariotype)?
Code List
Chloroma
CL Item
No (1)
C1298908 (UMLS CUI-1)
CL Item
Yes (2)
C1705108 (UMLS CUI-1)
CL Item
Not evaluated (3)
C3846720 (UMLS CUI-1)
CL Item
Unknown (4)
C0439673 (UMLS CUI-1)
Item
integer
C0205394 (UMLS CUI [1])
If abnormal: Are there 3 or more abnormalities (complex kariotype)?
Code List
Other
CL Item
No (1)
C1298908 (UMLS CUI-1)
CL Item
Yes (2)
C1705108 (UMLS CUI-1)
CL Item
Not evaluated (3)
C3846720 (UMLS CUI-1)
CL Item
Unknown (4)
C0439673 (UMLS CUI-1)
Item Group
C0472699 (UMLS CUI-1)
Item
integer
C0472699 (UMLS CUI [1])
HSCT
Code List
HSCT
CL Item
Allogeneic: Proceed to Status of disease at HSCT (1)
C1705576 (UMLS CUI-1)
CL Item
Autologous (2)
C0194037 (UMLS CUI-1)
Date of Collection
Item
Date of Collection
date
C3827940 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Treatment Number Chemotherapy
Item
Number of chemotherapy course(s) from last CR to stem cell collection (fill in only if patient had a CR prior to this HSCT )
float
C0392920 (UMLS CUI [1])
C1302181 (UMLS CUI [2,1])
C0750480 (UMLS CUI [2,2])
Number of chemotherapy course(s) from collection to HSCT
Item
Number of chemotherapy course(s) from collection to HSCT
text
C0392920 (UMLS CUI [1])
Item
integer
C1302181 (UMLS CUI [1])
Disease Hematological Status
Code List
Disease Hematological Status
CL Item
Initial diagnosis / Untreated (1)
C0746919 (UMLS CUI-1)
CL Item
Primary induction failure (2)
C2347677 (UMLS CUI-1)
CL Item
Complete Remission Number of this remission 1st  (3)
C0677874 (UMLS CUI-1)
C0205435 (UMLS CUI-2)
CL Item
Complete Remission Number of this remission 2nd (4)
C0677874 (UMLS CUI-1)
C0205436 (UMLS CUI-2)
CL Item
Complete Remission Number of this remission 3rd or higher (5)
C0677874 (UMLS CUI-1)
C0205437 (UMLS CUI-2)
CL Item
Relapse Number of this relapse 1st  (6)
C0035020 (UMLS CUI-1)
C0205435 (UMLS CUI-2)
CL Item
Relapse Number of this relapse 2nd (7)
C0035020 (UMLS CUI-1)
C0205436 (UMLS CUI-2)
CL Item
Relapse Number of this relapse 3rd or higher (8)
C0035020 (UMLS CUI-1)
C0205437 (UMLS CUI-2)
Item
Complete cytogenetic remission (fill in only if cytogenetic abnormality/ies detected at diagnosis)
integer
C0010802 (UMLS CUI [1,1])
C0677874 (UMLS CUI [1,2])
Complete cytogenetic remission
Code List
Complete cytogenetic remission (fill in only if cytogenetic abnormality/ies detected at diagnosis)
CL Item
No: Persistence of previously detected abnormality/ies (1)
CL Item
Yes: Absence of previously detected abnormality/ies (2)
CL Item
Not Done / Not available (3)
Item
Complete molecular remission (fill in only if molecular abnormality/ies detected at diagnosis)
integer
C0026376 (UMLS CUI [1,1])
C0677874 (UMLS CUI [1,2])
Complete cytogenetic remission
Code List
Complete molecular remission (fill in only if molecular abnormality/ies detected at diagnosis)
CL Item
No: Persistence of previously detected abnormality/ies (1)
CL Item
Yes: Absence of previously detected abnormality/ies (2)
CL Item
Not Done / Not available (3)
Item Group
C1704632 (UMLS CUI-1)
C0472699 (UMLS CUI-2)
Item
Hematological status (considering number of blasts in bone marrow)
integer
C1302181 (UMLS CUI [1])
Disease Hematological Status
Code List
Hematological status (considering number of blasts in bone marrow)
CL Item
Initial diagnosis / Untreated (1)
C0746919 (UMLS CUI-1)
CL Item
Primary induction failure (2)
C2347677 (UMLS CUI-1)
CL Item
Complete Remission Number of this remission 1st  (3)
C0677874 (UMLS CUI-1)
C0205435 (UMLS CUI-2)
CL Item
Complete Remission Number of this remission 2nd (4)
C0677874 (UMLS CUI-1)
C0205436 (UMLS CUI-2)
CL Item
Complete Remission Number of this remission 3rd or higher (5)
C0677874 (UMLS CUI-1)
C0205437 (UMLS CUI-2)
CL Item
Relapse Number of this relapse 1st  (6)
C0035020 (UMLS CUI-1)
C0205435 (UMLS CUI-2)
CL Item
Relapse Number of this relapse 2nd (7)
C0035020 (UMLS CUI-1)
C0205436 (UMLS CUI-2)
CL Item
Relapse Number of this relapse 3rd or higher (8)
C0035020 (UMLS CUI-1)
C0205437 (UMLS CUI-2)
Item
Complete cytogenetic remission (fill in only if cytogenetic abnormality/ies detected at diagnosis)
integer
C0010802 (UMLS CUI [1,1])
C0677874 (UMLS CUI [1,2])
Complete cytogenetic remission
Code List
Complete cytogenetic remission (fill in only if cytogenetic abnormality/ies detected at diagnosis)
CL Item
No: Persistence of previously detected abnormality/ies (1)
CL Item
Yes: Absence of previously detected abnormality/ies (2)
CL Item
Not Done / Not available (3)
Item
Complete molecular remission (fill in only if molecular abnormality/ies detected at diagnosis)
integer
C0026376 (UMLS CUI [1,1])
C0677874 (UMLS CUI [1,2])
Complete cytogenetic remission
Code List
Complete molecular remission (fill in only if molecular abnormality/ies detected at diagnosis)
CL Item
No: Persistence of previously detected abnormality/ies (1)
CL Item
Yes: Absence of previously detected abnormality/ies (2)
CL Item
Not Done / Not available (3)
Item Group
C1706712 (UMLS CUI-1)
Item
integer
C1706712 (UMLS CUI [1])
Additional disease treatment
Code List
Additional disease treatment
CL Item
No (1)
C1298908 (UMLS CUI-1)
CL Item
Yes, Planned (planned before HSCT took place) (2)
C0205539 (UMLS CUI-1)
CL Item
Yes, Not planned (for relapse/progression or persistant disease) (3)
C3854240 (UMLS CUI-1)
Item Group
C1704632 (UMLS CUI-1)
Item
integer
C1704632 (UMLS CUI [1])
Best response at 100 days after HSCT
Code List
Best response at 100 days after HSCT
CL Item
CR (maintained or achieved) (1)
C0677874 (UMLS CUI-1)
CL Item
Relapse / progression (2)
C0035020 (UMLS CUI-1)
C0242656 (UMLS CUI-2)
CL Item
Death (3)
C0011065 (UMLS CUI-1)
CL Item
Not evaluable (4)
C1883425 (UMLS CUI-1)
CL Item
Unknown (5)
C0439673 (UMLS CUI-1)
CR Date
Item
If complete response: date of CR
date
C0677874 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Item Group
C2985594 (UMLS CUI-1)
AUTOgraft, proceed to Autograft form
Item
text
ALLOgraft or Syngeneic graft, proceed to Allograft form
Item
text
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