Description:

2100 Revision 2 - 100 Days Post-HSCT Data Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9FB3D5BF-EA64-EEEB-E040-BB89AD4331BD

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9FB3D5BF-EA64-EEEB-E040-BB89AD4331BD

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Versions (6) ▾
  1. 9/19/12
  2. 7/17/17
  3. 7/17/17
  4. 7/17/17
  5. 7/17/17
  6. 9/20/21
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September 20, 2021

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Creative Commons BY-NC 3.0
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Hematopoietic Stem Cell Transplantation

Information should come from an actual examination by the Transplant Center physician, or the local physician who is following the recipient post-HSCT.

Registry Use Only
Identification Data
HSCT Type
HSCT type
Was a particular hematopoietic stem cell source used?
What type of hematopoietic stem cell transplant was used?
Was a particular hematopoietic stem cell transplant type used?
Vital Status
Did this patient receive the scheduled HSCT?
Reason
Did the recipient receive a subsequent HSCT?
Specify the recipient's survival status at the date of last contact
Has the recipient received a donor cellular infusion?
Hematopoietic Reconstitution Post-HSCT
Type
Were hematopoietic, lymphoid growth factors or cytokines administered?
Specify the indication for the therapy
Specify the specific G-CSF drug given
Specify the specific erythropoietin drug given
Granulopoiesis / Neutrophil Recovery
Was there evidence of hematopoietic recovery?
Did the recipient recover and maintain ANC greater than or equal to 500/mmE3 following the decline?
What is the unit of measure for WBC?
%
Megakaryopoiesis / Platelet Recovery
Was an initial platelet count greater than or equal to 20 x 10E9/L achieved?
Was an initial platelet count greater than or equal to 50 x 10E9/L achieved?
Current Hematologic Findings
What is the unit of measure for WBC?
%
%
What is the unit of measure for hemoglobin?
%
What is the unit of measure for platelets?
Immune Reconstitution
Type of immunologic laboratory procedure performed
Specify the unit of measure for the immunoglobulin test
Did the recipient receive supplemental intravenous immunoglobulins?
Was therapy ongoing within one month of immunoglobulin testing?
Specify the indication(s) for the supplemental intravenous immunoglobulin therapy
Specify if there was an indication for the supplemental intravenous immunoglobulin therapy
Were lymphocyte analyses performed?
Specify cluster of differentiation type
What is the unit of measure for the cluster of differentiation?
Chimerism Studies
Were chimerism studies performed?
Is a copy of the lab report attached?
Were infusions from more than one donor given?
Specify donor gender
Chimerism Studies
Method
Cell type
%
Were donor cells present as determined by non-quantitative means?
%
Were host cells present as determined by non-quantitative means?
Chimerism Studies
What is the transplant donor or infant gender?
Method
Cell type
%
Were donor cells present as determined by non-quantitative means?
%
Were host cells present as determined by non-quantitative means?
Engraftment Syndrome
Did engraftment syndrome occur?
Specify the symptoms of engraftment syndrome
%
Was engraftment syndrome treated with corticosteroids
Acute Graft versus Host Disease (GVHD)
Was specific therapy used to prevent acute GVHD or graft rejection, or for autologous HSCT to induce acute GVHD?
KGF
Velafermin
Did acute GVHD occur?
Was the diagnosis based on evidence from a biopsy?
What is the biopsy site used to indicate the diagnostic evidence
Specify result
Is a copy of the pathology report attached?
Was the diagnosis based on clinical evidence?
Maximum overall grade of acute GVHD
Is acute GVHD still present at the date of contact for this report?
List the maximum severity of skin involvement
List the maximum severity of lower intestinal tract involvement
List the maximum severity of upper intestinal tract involvement
List the maximum severity of liver involvement
Other clinical organ involvement?
Specify the site of organ involvement
Was a particular site of organ involvement present?
Was specific therapy used to treat acute GVHD?
ALS, ALG, ATS, ATG
Specify source
Corticosteroids
Corticosteroids
Cyclosporine
ECP
FK 506
In vivo monoclonal antibody
Anti CD 25
Campath
Etanercept
Infliximab
Other in vivo monoclonal antibody
In vivo immunotoxin
Methotrexate
Mycophenolate mofetil
Sirolimus
Ursodiol
Blinded randomized trial
Other agent
Chronic Graft Vs. Host Disease (gvhd)
Has the recipient developed clinical chronic GVHD?
Onset of chronic GVHD was
Specify the functional status
What is the unit of measure for platelets?
Diagnosis was based on
Maximum grade of chronic GVHD
Overall severity of chronic GVHD
Specify the type of organ / system involvement with chronic GVHD
Indicate if there was an organ / system involvement with chronic GVHD
Indicate if the organ / system involvement was proven by biopsy
Was specific therapy used to treat chronic GVHD?
ALS, ALG, ATS, ATG
Specify source
Azathioprine
Corticosteroids
Corticosteroids
Cyclosporine
ECP
Etretinate
FK 506
Hydroxychloroquine
In vivo monoclonal antibody
Anti CD 25
Campath
Etanercept
Infliximab
Other in vivo monoclonal antibody
Lamprene
Mycophenolate mofetil
Pentostatin
PUVA
Sirolimus
Thalidomide
Ursodiol
Blinded randomized trial
Other agent
Are symptoms of chronic GVHD still present?
Is the recipient still taking immunosuppressive agents to treat or prevent GVHD?
Infection
Specify the agent types received for infection prophylaxis
Did the recipient receive any of the following agents for infection prophylaxis?
Did the recipient receive irradiated granulocyte infusions?
Did the recipient develop a clinically significant infection?
Specify the viral organism
Select the infection organism site
Did the recipient develop more than 7 infections?
Are extra pages attached?
Organ Function - Pulmonary Function
Did the recipient develop interstitial pneumonitis / idiopathic pneumonia syndrome?
Were diagnostic tests done?
Was an organism isolated?
Adenovirus
Cytomegalovirus
Herpes simplex
HHV6
Parainfluenza
Respiratory syncytial virus
Toxoplasma
Other virus
Other organism
Did the recipient experience two or more episodes of IPn / IPS?
Are extra pages attached?
Did the recipient develop non-infectious pulmonary abnormalities?
Did the recipient develop bronchiolitis obliterans?
Did the recipient develop pulmonary hemorrhage?
Did the recipient develop cryptogenic organizing pneumonia?
Were diagnostic tests done?
Bronchoalveolar lavage
Transbronchial biopsy
Open / thorascopic lung biopsy
Autopsy
Other
Did the recipient develop any other non-infectious pulmonary abnormalities?
Did the recipient receive endotracheal intubation or mechanical ventilation?
Organ Function - Liver Function
Did the recipient develop non-infectious liver toxicity?
Cirrhosis
Veno-occlusive disease / sinusodial obstruction syndrome
Did the recipient receive treatment for VOD?
Did VOD resolve?
Other
Unknown
Specify diagnosis of liver toxicity by clinical signs and symptoms / evaluation
Was the diagnosis of liver toxicity determined by clinical signs and symptoms / evaluation
Organ Function - Other Organ Impairment / Disorder
Has the recipient developed any other clinically significant organ impairment or disorder?
Specify impairment / disorder
Did a particular type of organ impairment / disorder occur?
Did the recipient receive plasmapheresis?
Did the recipient receive dialysis?
Organ Function - New Malignancy
For all new malignancies except for "other skin malignancy (basal cell, squamous)," was testing performed to determine the cell of origin?
Specify the cell origin of the new malignancy
Is a copy of the lab report attached?
Specify which new disease(s) occurred
Did a new malignancy occur?
Is the tumor EBV positive?
Is a pathology / autopsy report or other documentation attached?
Functional Status
Was the recipient discharged from the hospital after HSCT?
days
Which scale was used to measure/report the functional status?
Karnofsky Performance Status Score
Lansky Performance Status Score
Subsequent HSCT
Was the subsequent HSCT performed at a different institution?
What was the indication for the subsequent HSCT?
Source of HSCs
Was the same donor used?
Specify
Donor Cellular Infusion (DCI) Information
Was the DCI infusion performed at a different institution?
Indication for DCI
Molecular
Cytogenetic
Clinical evidence / hematologic
Was chemotherapy used to attempt to induce disease response?
Specify the viral organism
What was the recipient's disease status?
Specify the functional status
Collected at the time of PBSC mobilization and collection
Negative fraction of CD34 selected PBSC
Negative fraction of CD34 selected bone marrow
Apheresis at a different time than collection of PBSC used for allogeneic HSCT
Isolated from a unit
Were the donor cells collected by leukapheresis?
Did the donor receive treatment to enhance cell collection prior to donation?
Growth factor
G-CSF
GM-CSF
Other agent
Other treatment
Were dendritic cells infused?
Were fibroblasts infused?
Were any other cell types infused?
Were the cells cryopreserved prior to infusion?
Specify portion of cells cryopreserved prior to infusion
Was the product manipulated prior to infusion?
Specify portion manipulated
ABO incompatibility
Buffy coat preparation
Cell separator
Density gradient separation
Plasma removal
Sedimentation
Other
Dextran-albumin wash
Ex-vivo expansion
Genetic manipulation
Volume reduction
CD34+ selection
Specify manufacturer
T-cell depletion
Antibody affinity column
Antibody coated plates
Antibody coated plates and soybean lectin
Antibody and complement
Antibody and toxin
Immunomagnetic beads
Elutriation
CD34 affinity column plus sheep red blood cell rosetting
Other
Other cell manipulation
Were antibodies used during graft manipulation?
Anti CD2
Anti CD4
Anti CD5
Anti CD6
Anti CD7
Anti CD8
Anti CD34
Anti TCR alpha / beta
OKT-3
Other CD3
Anti CD52
Campath-NOS
Campath-1G
Campath-1H
Other antibody
Author Information

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