Other Acute Leukemia Pre-HCT Disease Evaluation

*The timeline requirements for this form are as follows:
Assessment Time Frame: Within 45 days prior to the anticipated start of the conditioning regimen.
Submission Time Frame: Within 5 business days of collection.

*This form will only appear in the EDC if the “Specify the disease indication at diagnosis” field on Recipient Disease form is answered Other acute leukemia.

Disease Classification

Specify the acute leukemia classification at diagnosis:
Report recipient disease classification for Other Acute Leukemia from the available options in the dropdown list.

• Blastic plasmacytoid dendritic cell neoplasm
• Mixed phenotype acute leukemia (MPAL) with t(9;22)(q34.1;q11.2); BCR-ABL1
• Mixed phenotype acute leukemia with t(v; 11q23.3); KMT2A rearranged
• Mixed-phenotype acute leukemia with ZNF384 rearrangement
• Acute leukemia of ambiguous lineage with BCL11B rearrangement
• Mixed phenotype acute leukemia, B/myeloid
• Mixed phenotype acute leukemia, T/myeloid
• Mixed phenotype of acute leukemia, rare types
• Acute leukemia of ambiguous lineage, not otherwise specified
• Acute undifferentiated leukemia

Specify the pre-transplant disease status:
Report the subject’s pre-transplant disease status from the options available in the EDC.

Completion Remission (CR) is defined as:

• <5% blasts in the bone marrow
• No circulating blasts
• No evidence of extramedullary disease
  

CCG v1.0 | CRF v1.3

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