Patient
Identification code
text
Patient code
text
Initials (first name(s) - surname(s))
text
Patient date of birth
date
Sex
text
AB0 Group
text
Rh factor
text
Disease
Date of diagnosis
date
Primary disease diagnosis
integer
Specify
text
Initial Diagnosis
SubmittedPreviously
integer
Diagnosis
integer
Specify
text
WHO Classification AML
integer
Acute myeloid leukaemia, not otherwise categorized, classify as
integer
Specify
text
WHO Classification at diagnosis of de novo Precursor Lymphoid Neoplasms (old ALL)
integer
Specify
text
Secondary origin
integer
Cytgenetics
Chromosome analysis
integer
If abnormal: Are there 3 or more abnormalities (complex kariotype)?
integer
If done: number of metaphases with abnormalites
float
number of metaphases examined
float
Indicate which abnormalities found
integer
Number of chromosomes
integer
Other or associated abnormalities (specify, including whether absent or present)
text
Molecular Biology
Molecular markers
integer
BCR-ABL
integer
PML-RAR
integer
AML1-ETO
integer
FLT3-ITD
integer
CEBPA mutation
integer
NPM1 mutation
integer
MLL-PTD
integer
Other
integer
Specify
text
WBC
float
WBC not available/unknown
integer
Involvement at Diagnosis
BM
integer
CNS
integer
Testis/ovary
integer
Chloroma
integer
Other
integer
Type of HSCT
Treatment and Status of Disease at Stem Cell Collection
Date of Collection
date
Treatment Number Chemotherapy
float
Number of chemotherapy course(s) from collection to HSCT
text
Disease Hematological Status
integer
Complete cytogenetic remission
integer
Complete molecular remission
integer
Status of Disease at HSCT
Hematological status
integer
Complete cytogenetic remission
integer
Complete molecular remission
integer
Additional Treatment Post-HSCT
Best disease response at 100 days post-HSCT
Forms to be filled in