GENERAL INFORMATION Patient
Unique Identification Code (UIC)
text
Hospital Unique Patient Number or Code
text
Initials
text
Date of birth
date
Sex
integer
ABO Group
integer
Rh factor
integer
DISEASE
Date of Diagnosis
date
Primary Disease Diagnosis
text
Primary Disease Diagnosis
text
SPECIFICATIONS OF THE DISEASE MYELOPROLIFERATIVE NEOPLASM DIAGNOSIS
SUBCLASSIFICATION
integer
Chronic eosinophilic leukaemia (CEL)
integer
Cytogenetics Data
text
Chromosome analysis
text
Chromosome analysis
integer
number of metaphases with abnormalites
integer
number of metaphases examined
integer
Abnormality chr. 1
integer
Abnormality chr. 5
integer
Abnormality chr. 7
integer
trisomy 8
integer
trisomy 9
integer
del 20
integer
del 13
integer
Other abnormalities
integer
Molecular markers
integer
JAK2 mutation
integer
BCR/ABL
integer
FIP1L1-PDGFR
integer
HAEMATOLOGICAL VALUES Peripheral bloodc
integer
HbLab
float
Platelets
float
White Blood Cells
float
Blasts
float
Monocytes
float
neutrophils
float
Bone marrow Blasts
integer
Auer rods present
integer
RISK FACTOR SCORE
integer
BM INVESTIGATION
integer
FIBROSIS/OSTEOSCLEROSIS ON BM BIOPSY
integer
CONSTITUTIONAL SYMPTOMS
integer
Palpable Splenomegaly
integer
Physical examination
integer
Spleen span in ultrasound or CT scan
float
Weight loss
integer
FIRST LINE THERAPY
(If No, proceed to `Subclassification & Status of Disease at HSCT` If Yes, specify start date)
boolean
SUBCLASSIFICATION AT PRIMARY TREATMENT
integer
If transformed into Myelofibrosis or AML
date
TREATMENT
boolean
Chemo/drug/agent
integer
Radiotherapy
boolean
Radiotherapy
integer
* CR must include all three conditions: 1. Resolution of disease –related symptoms and signs including palpable hepato-splenomegaly 2. Hb >11gr/dL, Platelet >100 x109/L and neutrophils >1 x 109/L. 3. normal bone marrow histology, and fibrosis grade no higher than 1
integer
SUBCLASSIFICATION & STATUS OF DISEASE AT HSCT
Date of HSCT
date
Splenectomy
integer
Transfusional status at HSCT
integer
SUBCLASSIFICATION AT HSCT
integer
If transformed into Myelofibrosis or AML, date of transformation
date
STATUS OF DISEASE AT HSCT
integer
NUMBER OF STATUS OF DISEASE AT HSCT
integer
(Within 2 months of the preparative -conditioning- regimen)
integer
Chromosome analysis
integer
Indicate which abnormalities found
integer
Indicate which abnormalities found
float
Indicate which abnormalities found
integer
Indicate which abnormalities found
integer
Indicate which abnormalities found
integer
Indicate which abnormalities found
integer
Indicate which abnormalities found
integer
HAEMATOLOGICAL VALUES
integer
Bone marrow
integer
Lille score
integer
Cervantes score
integer
BM Investigation
text
(at diagnosis; check one box in each column)
integer
FIBROSIS/OSTEOSCLEROSIS ON BM BIOPSY
integer
CONSTITUTIONAL SYMPTOMS
integer
Palpable Splenomegaly
text
Physical examination
integer
Physical examination below costal margin
float
Spleen span in ultrasound or CT scan
float
Weight loss
integer
ADDITIONAL TREATMENT POST-HSCT
RESPONSE OF DISEASE
FORMS TO BE FILLED IN
TYPE OF TRANSPLANT
integer
TYPE OF TRANSPLANT
integer