The Myeloproliferative Neoplasms Pre-HCT Data Form is one of the Comprehensive Report Forms. This form captures MPN-specific pre-HCT data such as: disease assessment at diagnosis, laboratory studies at diagnosis, pre-HCT therapy, disease transformation, most recent disease assessments, laboratory studies, and disease status prior to the preparative regimen.

This form must be completed for all recipients who are randomized to the Comprehensive Report Form (CRF) track and whose primary disease is reported on the Pre-TED Disease Classification Form (Form 2402) as “Myeloproliferative (MPN) diseases (50) and recipients with AML whose disease progressed from MPN.

Links to Sections of Form:
Q1: Subsequent Transplant
Q2-10: Disease Assessment at Diagnosis
Q11-40: Diagnostic Studies
Q41-54: DIPSS Prognosis Score
Q55-212: Pre-HCT / Pre-Infusion Therapy
Q213-254: Laboratory Studies at Last Evaluation Prior to the Start of the Preparative Regimen / Infusion
Q255-261: Disease Assessment at the Last Evaluation Prior to the Preparative Regimen / Infusion

Manual Updates:
Sections of the Forms Instruction Manual are frequently updated. The most recent updates to the manual can be found below. For additional information, select the manual section and review the updated text. If you need to reference the historical Manual Change History for this form, please reference the retired manual section on the Retired Forms Manuals webpage.

Date Manual Section Add/Remove/Modify Description
10/7/2020 2057: Myeloproliferative Neoplasm (MPN) Pre-Infusion Add Clarification added to question 55 to explain how to report lines of therapy for subsequent infusions: Lines of Therapy and Subsequent Infusions
If this is a subsequent infusion and a 2057 was completed for the previous infusion, lines of therapy do not need to be reported in duplication on the subsequent 2057. Please report from post previous infusion to time of preparative regimen / infusion for the current infusion. If a 2057 was not previously completed, all lines of therapy from diagnosis to the current preparative regimen / infusion must be completed.
7/24/2020 2057: MPN Pre-Infusion Add Added the following warning box (in red below) above question 250:
Total Serum Ferritin
Questions 250-252 are disabled and cannot be answered at this time. The total serum ferritin is already captured in the “Comorbid Conditions” section of the Pre-TED (2400) Form (questions 103-106).
5/10/2020 2057: Myeloproliferative Neoplasm (MPN) Pre-Infusion Add Version 1 of the 2057: MPN Pre-Infusion section of the Forms Instruction Manual released. Version 1 corresponds to revision 1 of the Form 2057.
Last modified: Oct 07, 2020

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