Questions 1-3: Specify the new malignancy:

Indicate which new malignancy / disorder was diagnosed during the reporting period. If the new malignancy / disorder is not found in the list, select ‘other new malignancy’ and specify in question 2. Report the date of diagnosis in question 3, using the pathologic diagnosis date. If the original assessment confirming diagnosis is not available, report the date of diagnosis indicated in the progress notes.

For more information regarding reporting partial or unknown dates, see General Instructions, General Guidelines for Completing Forms.

Question 4 & 5: Was the new malignancy donor / cell product derived?

Indicate whether the new malignancy originated from the donor / cell product. If “yes,” indicate whether documentation was submitted to CIBMTR (e.g., cell origin evaluation (VNTR, cytogenetics, FISH)) in question 5.

For further instructions on how to attach documents in FormsNet3SM, refer to the Training Guide.

Question 6: Was documentation submitted to the CIBMTR? (e.g. pathology report, autopsy report)

Indicate whether documentation of the new malignancy, lymphoproliferative disorder, or myeloproliferative disorder was submitted to CIBMTR (e.g., pathology report, autopsy report).
For further instructions on how to attach documents in FormsNet3SM, refer to the Training Guide.

Post-Transplant Lymphoproliferative Disorder

Question 7: Was there EBV reactivation in the blood?

If reactivation in the blood was confirmed during the reporting period, report “yes” and continue with question 8. If reactivation did not occur during the reporting period report “no” and continue with question 13.

Indicate “unknown” if no EBV testing was performed during the reporting period and continue with question 13.

Question 8-12: How was EBV reactivation diagnosed?

Indicate the method of detection for EBV reactivation.

If reactivation was diagnosed by “qualitative PCR of blood,” continue with question 13.

If the diagnosis was made by “quantitative PCR of blood,” report the number of copies detected in question 10. Also, indicate whether repeat testing was performed during the reporting period in question 11. If repeat testing was performed, report the results of the most recent test performed during the reporting period in question 12.

If the diagnosis was made by “other method,” specify the method of detection in question 9 and then continue with question 13.

Question 13: Was there lymphomatous involvement? (e.g., a mass)

Indicate whether a mass or other lymphomatous involvement was detected during the reporting period. If there was lymphomatous involvement was confirmed during the reporting period, report “yes” and continue with question 14. If lymphomatous involvement was not confirmed during the reporting period, report “no” and continue with question 22.

Question 14-21: Specify sites of PTLD involvement:

For each site listed, indicate whether there was post-transplant lymphoproliferative disorder (PTLD) involvement. Sites may be identified by radiographic or pathologic methods. If there was PTLD involvement at a site not listed, report “other site” in question 20 and specify in question 21.

Question 22 & 23: Was PTLD confirmed by biopsy?

Indicate whether PTLD was confirmed by a biopsy. If PTLD was confirmed by a biopsy, report “yes” and indicate whether documentation was submitted to CIBMTR (e.g., pathology report) in question 23. If a biopsy did not confirm the diagnosis of PTLD, report “no”.

For further instructions on how to attach documents in FormsNet3SM, refer to the Training Guide.

Last modified: Jan 30, 2018

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