WHIForm 349– LILAC LymphomaAbstraction Form Ver. 1V
CCC Coder ID: ______
Member ID:__ __ - ______- __Case #: ______CCC ID: ______
Other Case #s:______Date completed: __ __ /__ __ / __ __ (MM/DD/YY)
Histology: ______
1.Was any cancer-directed surgery done as part of primary treatment for lymphoma?
0No
9Unknownif cancer-directed surgery performedGo to Question 2.
(e.g., death certificate ONLY)
1Yes
1.1Type of surgery: (Mark all that apply.)1Splenectomy3Lymph node dissection
2Local tumor excision8Other surgery(Specify): ______
1.2Surgery Date: __ __ /__ __ /__ __1Exact2Estimated9Unknown
Month Day Year
2.Was molecular testing documented in the medical records as part of the initial work-up?
1 Yes 0 No
2 Recommended, unknown if done Go to Question 3.
9 Unknown
Go to Question 2.1.
R:\Document\Ext 2\Forms\CURR\F349V1V.docpg. 1of79/20/17
WHIForm 349 – LILAC LymphomaAbstraction FormVer. 1V
Mark all that apply:2.1 / Specify Test / Date / Result / Assay Type
(See table)
Expressions
1 / CD10 / __ __ /__ __ /__ __ / 1 Exact2 Estimated9 Unknown / 0Negative2Borderline
1Positive9 Unknown
2 / BCL6 / __ __ /__ __ /__ __ / 1 Exact2 Estimated9 Unknown / 0Negative2Borderline
1Positive9 Unknown
3 / MUM1 (Interferon regulatory factor 4 [IRF4]) / __ __ /__ __ /__ __ / 1 Exact2 Estimated9 Unknown / 0Negative2Borderline
1Positive9 Unknown
4 / BCL2 / __ __ /__ __ /__ __ / 1 Exact2 Estimated9 Unknown / 0Negative2Borderline
1Positive9 Unknown
Translocations
5 / ALK / __ __ /__ __ /__ __ / 1 Exact2 Estimated9 Unknown / Translocation present:
0No2Equivocal
1 Yes9Unknown
6 / MYC (c-MYC) / __ __ /__ __ /__ __ / 1 Exact2 Estimated9 Unknown / Translocation present:
0No2Equivocal
1 Yes9Unknown
7 / BCL2 / __ __ /__ __ /__ __ / 1 Exact2 Estimated9 Unknown / Translocation present:
0No2Equivocal
1 Yes9Unknown
8 / BCL6 / __ __ /__ __ /__ __ / 1 Exact2 Estimated9 Unknown / Translocation present:
0No2Equivocal
1 Yes9Unknown
Specify Test
(Translocations cont’d.) / Date / Result / Assay Type
(See table)
9 / IGH/
Immunoglobulin / __ __ /__ __ /__ __ / 1 Exact2 Estimated9 Unknown / Translocation present:
0No2Equivocal
1 Yes9Unknown
88 / Other(Specify): ______
______/ __ __ /__ __ /__ __ / 1 Exact2 Estimated9 Unknown / Translocation present:
0No2Equivocal
1 Yes9Unknown
99 / Unknown / __ __ /__ __ /__ __ / 1 Exact2 Estimated9 Unknown / Translocation present:
0No2Equivocal
1 Yes9Unknown
Assay Table
Assay
1 / Immunohistochemistry (IHC) / Typically a stained slide from tumor sample
2 / Flow Cytometry / Flow trumps an IHC test when both tests are completed
3 / Fluorescence based in situ hybridization (FISH) / FISH trumps an IHC test when both tests are completed
4 / Gene Expression Profiling (GEP) / Typically done on a tumor sample
5 / Karyotype
8 / Other, Specify
9 / Unknown
R:\Document\Ext 2\Forms\CURR\F349V1V.docpg. 1of79/20/17
WHIForm 349 – LILAC LymphomaAbstraction Form Ver. 1V
3.Waschemotherapy, immune-modulating, or targeted therapy administered as part of the first course of therapy? Do not include conditioning chemo (BMT/SCT).
1Yes0No
2Recommended, unknown if doneGo to Question 4.
9Unknown
3.1Regimen Name: Code:1Adjuvant therapy2Neoadjuvant therapy
Start date:__ __ / __ __ / __ __1Exact2Estimated9Unknown
Month Day Year
Administration route:1Oral8Other: ______
(Mark all that apply.)2IV9Unknown
3.2Regimen Name: Code:
1Adjuvant therapy2Neoadjuvant therapy
Start date:__ __ / __ __ / __ __1Exact2Estimated9Unknown
Month Day Year
Administration route:1Oral8Other: ______
(Mark all that apply.)2IV9Unknown
3.3Regimen Name: Code:
1Adjuvant therapy2Neoadjuvant therapy
Start date:__ __ / __ __ / __ __1Exact2Estimated9Unknown
Month Day Year
Administration route:1Oral8Other: ______
(Mark all that apply.)2IV9Unknown
3.4Regimen Name: Code:
1Adjuvant therapy2Neoadjuvant therapy
Start date:__ __ / __ __ / __ __1Exact2Estimated9Unknown
Month Day Year
Administration route:1Oral8Other: ______
(Mark all that apply.)2IV9Unknown
3.5Regimen Name: Code:
1Adjuvant therapy2Neoadjuvant therapy
Start date:__ __ / __ __ / __ __1Exact2Estimated9Unknown
Month Day Year
Administration route:1Oral8Other: ______
(Mark all that apply.)2IV9Unknown
4.Was radiationtherapygivenas part ofthe first course of therapy?
1Yes0No
2Recommended, unknown if doneGo to Question 5.
9Unknown
4.1What type of radiation was administered? (Mark all that apply.)1External beam radiation therapy (EBRT) at tumor site
8Other(Specify): ______
9Unknown
4.2Start date:__ __ /__ __ /__ __1Exact2Estimated9Unknown
Month Day Year
Stop date:__ __ /__ __ /__ __1Exact2Estimated9Unknown
Month Day Year
Total dosage of radiation received: ______cGy/Rad9Unknown
5.Was radioimmunotherapy (radio labeled monoclonal antibodies) administered as part of the first course of therapy?
1Yes0No9Unknown
6. / Was endocrine-targeted/hormone therapy given?1Yes0 No
2Recommended, unknown if doneGo to Question 7.
9 Unknown
6.1Agent Name: Code: ______
Use:1Intermittent use2Continuous use9Unknown
Start date: __ __ / __ __ / __ __1 Exact2Estimated9Unknown
Month Day Year
End date or last documented use: __ __ / __ __ / __ __1 Exact2Estimated
Month Day Year3Current use9Unknown
6.2Agent Name: Code: ______
Use:1Intermittent use2Continuous use9Unknown
Start date: __ __ / __ __ / __ __1 Exact2Estimated9Unknown
Month Day Year
End date or last documented use: __ __ / __ __ / __ __1 Exact2Estimated
Month Day Year3Current use9Unknown
7.Were other treatments administered?
1Yes0No
9Unknown
7.1 / Type of treatment: (Mark all that apply.)1Watchful waiting
2Bone marrow transplant
3Stem cell transplant
8Other (Specify):
7.1.1Data of Procedure:__ __ / __ __ / __ __
Month Day Year
7.1.2Donor type
1Autologous
2Allogeneic
9 Unknown
7.1.3Conditioning regimen (Mark all that apply.)
1Chemotherapy(Names):
2Total body irradiation (Dosage):
8Other (Specify):
7.1.4Graft vs. Host disease requiring medical intervention
1Yes0No
9 Unknown
8.Has the participant ever been disease-free since the initial diagnosis/treatment?
1Yes
0No
9Unknown
* If no evidence of recurrence or metastasis: Record most recent documented disease-free date.
If documented recurrence or metastasis: Record first known disease-free date, if one exists.
9.Was there a new or evolvedlymphoma diagnosed? Code whether or not a disease-free interval exists.
1Yes0No9Unknown
9.1Histology:1Same disease process2Different disease process9UnknownSpecify histology:
Diagnosis date: __ __ / __ __ / __ __1Exact2Estimated9Unknown
Month Day Year
9.2Histology:1Same disease process2Different disease process9Unknown
Specify histology:
Diagnosis date: __ __ / __ __ / __ __1Exact2Estimated9Unknown
Month Day Year
10.Did a recurrence or metastasis occur after the initial diagnosis and after a documented disease-free interval?
1Yes0No
9Unknown
10.1 / Site(s): (Mark all that apply.)1Liver3Lymph nodes
2Bone marrow 8Other (Specify):
3Brain9Unknown
10.2 / Diagnosis date: __ __ / __ __ / __ __1Exact2Estimated9Unknown
Month Day Year
Comments:
R:\Document\Ext 2\Forms\CURR\F349V1V.docpg. 1of79/20/17