WHI Staging and Treatment (16156 - Activated, Traditional)

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.)
1Splenectomy3Lymph node dissection
2Local tumor excision8Other surgery(Specify): ______
1.2Surgery Date: __ __ /__ __ /__ __1Exact2Estimated9Unknown
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.

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WHIForm 349 – LILAC LymphomaAbstraction FormVer. 1V

Mark all that apply:
2.1 / Specify Test / Date / Result / Assay Type
(See table)
Expressions
1 / CD10 / __ __ /__ __ /__ __ / 1 Exact2 Estimated9 Unknown / 0Negative2Borderline
1Positive9 Unknown
2 / BCL6 / __ __ /__ __ /__ __ / 1 Exact2 Estimated9 Unknown / 0Negative2Borderline
1Positive9 Unknown
3 / MUM1 (Interferon regulatory factor 4 [IRF4]) / __ __ /__ __ /__ __ / 1 Exact2 Estimated9 Unknown / 0Negative2Borderline
1Positive9 Unknown
4 / BCL2 / __ __ /__ __ /__ __ / 1 Exact2 Estimated9 Unknown / 0Negative2Borderline
1Positive9 Unknown
Translocations
5 / ALK / __ __ /__ __ /__ __ / 1 Exact2 Estimated9 Unknown / Translocation present:
0No2Equivocal
1 Yes9Unknown
6 / MYC (c-MYC) / __ __ /__ __ /__ __ / 1 Exact2 Estimated9 Unknown / Translocation present:
0No2Equivocal
1 Yes9Unknown
7 / BCL2 / __ __ /__ __ /__ __ / 1 Exact2 Estimated9 Unknown / Translocation present:
0No2Equivocal
1 Yes9Unknown
8 / BCL6 / __ __ /__ __ /__ __ / 1 Exact2 Estimated9 Unknown / Translocation present:
0No2Equivocal
1 Yes9Unknown
Specify Test
(Translocations cont’d.) / Date / Result / Assay Type
(See table)
9 / IGH/
Immunoglobulin / __ __ /__ __ /__ __ / 1 Exact2 Estimated9 Unknown / Translocation present:
0No2Equivocal
1 Yes9Unknown
88 / Other(Specify): ______
______/ __ __ /__ __ /__ __ / 1 Exact2 Estimated9 Unknown / Translocation present:
0No2Equivocal
1 Yes9Unknown
99 / Unknown / __ __ /__ __ /__ __ / 1 Exact2 Estimated9 Unknown / Translocation present:
0No2Equivocal
1 Yes9Unknown
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

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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).

1Yes0No

2Recommended, unknown if doneGo to Question 4.

9Unknown

3.1Regimen Name: Code:
1Adjuvant therapy2Neoadjuvant therapy
Start date:__ __ / __ __ / __ __1Exact2Estimated9Unknown
Month Day Year
Administration route:1Oral8Other: ______
(Mark all that apply.)2IV9Unknown
3.2Regimen Name: Code:
1Adjuvant therapy2Neoadjuvant therapy
Start date:__ __ / __ __ / __ __1Exact2Estimated9Unknown
Month Day Year
Administration route:1Oral8Other: ______
(Mark all that apply.)2IV9Unknown
3.3Regimen Name: Code:
1Adjuvant therapy2Neoadjuvant therapy
Start date:__ __ / __ __ / __ __1Exact2Estimated9Unknown
Month Day Year
Administration route:1Oral8Other: ______
(Mark all that apply.)2IV9Unknown
3.4Regimen Name: Code:
1Adjuvant therapy2Neoadjuvant therapy
Start date:__ __ / __ __ / __ __1Exact2Estimated9Unknown
Month Day Year
Administration route:1Oral8Other: ______
(Mark all that apply.)2IV9Unknown
3.5Regimen Name: Code:
1Adjuvant therapy2Neoadjuvant therapy
Start date:__ __ / __ __ / __ __1Exact2Estimated9Unknown
Month Day Year
Administration route:1Oral8Other: ______
(Mark all that apply.)2IV9Unknown

4.Was radiationtherapygivenas part ofthe first course of therapy?

1Yes0No

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:__ __ /__ __ /__ __1Exact2Estimated9Unknown
Month Day Year
Stop date:__ __ /__ __ /__ __1Exact2Estimated9Unknown
Month Day Year
Total dosage of radiation received: ______cGy/Rad9Unknown

5.Was radioimmunotherapy (radio labeled monoclonal antibodies) administered as part of the first course of therapy?

1Yes0No9Unknown

6. / Was endocrine-targeted/hormone therapy given?
1Yes0 No
2Recommended, unknown if doneGo to Question 7.
9 Unknown
6.1Agent Name: Code: ______
Use:1Intermittent use2Continuous use9Unknown
Start date: __ __ / __ __ / __ __1 Exact2Estimated9Unknown
Month Day Year
End date or last documented use: __ __ / __ __ / __ __1 Exact2Estimated
Month Day Year3Current use9Unknown
6.2Agent Name: Code: ______
Use:1Intermittent use2Continuous use9Unknown
Start date: __ __ / __ __ / __ __1 Exact2Estimated9Unknown
Month Day Year
End date or last documented use: __ __ / __ __ / __ __1 Exact2Estimated
Month Day Year3Current use9Unknown

7.Were other treatments administered?

1Yes0No

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
1Yes0No
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.

1Yes0No9Unknown

9.1Histology:1Same disease process2Different disease process9Unknown
Specify histology:
Diagnosis date: __ __ / __ __ / __ __1Exact2Estimated9Unknown
Month Day Year
9.2Histology:1Same disease process2Different disease process9Unknown
Specify histology:
Diagnosis date: __ __ / __ __ / __ __1Exact2Estimated9Unknown
Month Day Year

10.Did a recurrence or metastasis occur after the initial diagnosis and after a documented disease-free interval?

1Yes0No

9Unknown

10.1 / Site(s): (Mark all that apply.)
1Liver3Lymph nodes
2Bone marrow 8Other (Specify):
3Brain9Unknown
10.2 / Diagnosis date: __ __ / __ __ / __ __1Exact2Estimated9Unknown
Month Day Year

Comments:

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