Q3 – 127: Acute Myelogenous Leukemia

Acute Myelogenous Leukemia (AML) is a cancer of the white blood cells. It is characterized by the rapid proliferation of abnormal, immature myelocytes, known as myeloblasts, in the bone marrow. This accumulation of blasts in the marrow prevents the formation of healthy red blood cells, white blood cells, and/or platelets. Normal myeloblasts develop into neutrophils, basophils, and eosinophils, which are all white blood cells that fight infection. In AML, the leukemic myeloblasts do not fully develop and are unable to fight infection. The symptoms of AML result from a drop in red blood cell, platelet, and normal white blood cell counts caused by the replacement of normal bone marrow with leukemic cells.

Certain prognostic indicators are associated with poorer outcomes. These include advanced age (50+ years of age), AML arising from MDS or secondary / therapy-related AML, and certain genetic mutations that are described in greater detail later in this manual.

Question 1: Date of diagnosis of primary disease for infusion

Report the date of the first pathological diagnosis (e.g., bone marrow or tissue biopsy) of the disease. Enter the date the sample was collected for examination. If the diagnosis was determined at an outside center, and no documentation of a pathological or laboratory assessment is available, the dictated date of diagnosis within a physician note may be reported. Do not report the date symptoms first appeared.

If AML transformed from MDS or MPN, report the diagnosis date of the AML. The MDS or MPN diagnosis date will be captured in the MDS or MPN sections below.

If the exact diagnosis date is not known, use the process described in General Instructions, Guidelines for Completing Forms

Question 3: Specify the AML classification

CIBMTR captures the classification of AML based on the World Health Organization (WHO) 2022 but also recognizes International Consensus Classification (ICC) 2022 and those classifications are also included, when applicable. Additionally, the European LeukemiaNet (ELN) 2022 is also included from a risk stratification standpoint. Indicate the disease classification at diagnosis.

Report the most specific entity that applies to the recipient. For example, if the disease classification is defined by both genetic abnormalities and differentiation, the defining genetic abnormality classification should be reported for classification purposes.

In some cases, disease specific cytogenetic and / or molecular abnormalities are not identified at the initial diagnosis but identified at some point prior to the infusion, report the most disease specific entity. Review the example below for further clarification:

• Example 1: A recipient diagnosed with AML had only a bone marrow biopsy and FISH testing for BCR-ABL performed at diagnosis. The bone marrow identified AML with maturation and FISH was negative for BCR-ABL. Induction began and additional molecular testing completed after starting treatment which identified NPM1. The disease classification should be reported as AML with NPM1 mutation.

For some AML classifications, the requirement of > 20% blasts in blood or bone marrow is no longer applicable. The guidelines below provide an overview of which AML classifications require > 20% blasts in the blood or bone marrow.

• If the disease is a ‘AML with defining genetic abnormalities,’ > 20% blasts in blood or bone marrow is no longer required, except for AML with BCR::ABL1 fusion, AML with CEBPA mutation, and AML with myelodysplasia – related.
  • For AML with BCR::ABL1 fusion and AML with CEBPA mutation, > 20% blasts in blood or bone marrow is required
  • For AML with myelodysplasia – related, the following is required:
    • > 20% blasts in blood or bone marrow are required, and one of the following:
      • History of MDS / MPN; or
      • At least one defining cytogenetic abnormality present; or
        • Complex karyotype (i.e., > 3 abnormalities)
        • Deletion or loss 5q
        • Monosomy 7, deletion, or loss 7q
        • Deletion 11q
        • Deletion or loss 12p
        • Monosomy 13 or deletion 13q
        • Deletion or loss 17p
        • Isochromosome 17q
        • Idic(X)(q13)
      • At least one defining somatic mutation present
        • ASXL1
        • BCOR
        • EZH2
        • SF3B1
        • SRSF2
        • STAG2
        • U2AF1
        • ZRSR2
  • If the disease is AML with other defined genetic alterations, > 20% blasts in blood or bone marrow is not required; however, seek physician clarification if it is unclear if the disease should be reported as AML.
• If the disease is a ‘AML, defined by differentiation,’ > 20% blasts in blood or bone marrow is required.
  

!Subsequent Infusion and Transformation, Therapy Related, and Predisposing Conditions
If this is a subsequent infusion for the same disease, the Did AML transform form MDS or MPN, Is the disease therapy related, and Did the recipient have predisposing condition questions are disabled.

Question 4: Did AML transform from MDS or MPN?

AML often evolves from MDS or MPN. This transformation is typically distinguished by the percentage of blasts in the bone marrow

AML that transforms from MDS or MPN has a lower survival prognosis because of the association with unfavorable cytogenetic abnormalities.

AML can also evolve from Juvenile Myelomonocytic Leukemia (JMML). JMML is a rare form of chronic leukemia that affects young children, usually before the age of five. JMML results from DNA mutations in cells called monocytes. Normal monocytes attack invading microorganisms and assist lymphocytes in carrying out immune functions. Abnormal monocytes in JMML accumulate in the bone marrow and interfere with the production of normal white blood cells, red blood cells, and platelets.

If AML transformed from MDS (including JMML), check Yes, MDS and complete both the AML and MDS disease classification section of the form.

If AML transformed from MPN, check Yes, MPN and complete both the AML and MPN disease classification section of the form.

If AML did not transform from MDS or MPN, check No.

Report No in the following scenarios:

• AML did not transform from MDS or MPN
• It is not known if AML transformed from MDS or MPN
• If MDS or MPN is suspected, but not confirmed by documented laboratory or pathologic finding
• There is a concurrent diagnosis of MDS or MPN and AML

Question 5: Is the disease (AML) therapy related?

Agents such as radiation or systemic therapy used to treat other diseases (e.g., Hodgkin lymphoma, non-Hodgkin lymphoma, or breast cancer) can damage the marrow and lead to a secondary malignancy such as AML. Indicate if the diagnosis of AML is therapy-related.

Select No for the following:

• If the diagnosis of AML is not therapy-related
• If AML was preceded by therapy-related MDS
• If the recipient developed AML after an environmental exposure (e.g., exposure to benzene)
  

If it is not known whether the diagnosis of AML was therapy-related, check Unknown.

If documentation is unclear, seek clinician clarification.

*Concurrent AML and MDS or MPN Diagnosis
If there is a concurrent diagnosis of AML and MDS or MPN, do not report there was a transformation above. Instead, report Yes there was a predisposing condition / antecedent hematologic disorder and specify the MDS or MPN classification.

Question 6: Did the recipient have a predisposing condition or antecedent hematologic disorder?

Certain predisposing conditions and antecedent hematologic disorders contribute to the susceptibility of developing leukemia. Therefore, diagnosis of specific conditions / disorders increases the likelihood that the recipient will develop leukemia.

Indicate if the recipient has a documented history of a predisposing condition or antecedent hematologic disorder. If there is no history of predisposing condition / antecedent hematologic disorder or it is not known, indicate No or Unknown, respectively.

Questions 7 – 8: Specify AML predisposing condition or antecedent hematologic disorder

Specify the recipient’s predisposing condition / antecedent hematologic disorder prior to the diagnosis of AML. If the recipient has a documented history of a predisposing condition / antecedent hematologic disorder but it is not listed as an option, select Other condition and specify the condition.

!Subsequent Infusion and At Diagnosis Time Point
If this is a subsequent infusion for the same disease, the at diagnosis time point is disabled.

*At Diagnosis Assessments
Assessments performed at diagnosis, last evaluation and in between are collected throughout the form to capture testing performed at different time points prior to infusion. For reporting purposes, at diagnosis time point is defined as any testing performed closest to (before or after) the date of diagnosis and prior to the start of any treatment for AML.

Question 9: Were cytogenetics tested (karyotyping or FISH)? (at diagnosis)

Cytogenetic analysis is the study of chromosomes. Cytogenetic assessment involves testing blood or bone marrow for the presence of a known chromosomal abnormality which reflects the recipient’s disease.

Testing methods you may see include conventional chromosome analysis (karyotyping) or fluorescence in situ hybridization (FISH). For more information about cytogenetic testing and terminology, see Appendix C, Cytogenetics.

Indicate if cytogenetic studies were obtained at diagnosis. If cytogenetic studies were obtained, select Yes. If no cytogenetic studies were obtained, or it is unknown if chromosome studies were performed, select No or Unknown, respectively.

Table 1. Examples of AML Cytogenetic Findings Categorized by Prognosis

Favorable	Intermediate	Poor
t(15;17) t(8;21) inv(16) or t(16;16)	Normal +8 t(9;11) All other abnormalities	≥ 3 abnormalities 5- or 5q- 7- or 7q- t(9;22)

Question 10: Were cytogenetics tested via FISH? (at diagnosis)

Specify if FISH studies were performed at diagnosis. If FISH studies were not performed at diagnosis, FISH samples were inadequate or the result ‘failed’, report No.

If it is not known if it was performed at diagnosis, report Unknown.

Report chromosomal microarrays / chromosomal genomic arrays as FISH assessments.

Question 11: Results of tests

Specify if FISH abnormalities were identified at diagnosis.

!International System for Human Cytogenetic Nomenclature (ISCN) Compatible String
The International System for Human Cytogenetic Nomenclature (ISCN) compatible string question is disabled and cannot be answered at this time.

*Submitting FISH Documentation
CIBMTR strongly encourages attaching the FISH report when abnormalities are identified. For further instructions on how to attach documents in FormsNet3^SM, refer to the Training Guide.

Questions 12 – 15: Specify FISH abnormalities (at diagnosis)

Report the International System for Human Cytogenetic Nomenclature (ISCN) compatible string, if the data field is enabled. Refer to Appendix C: Cytogenetics for more information on how to report using the ISCN functionality.

If the ISCN compatible string is not reported, then select the number of abnormalities detected by FISH at diagnosis and select all abnormalities detected.

If a clonal abnormality is detected, but not listed as an option, select Other abnormality and specify the abnormality. If multiple other abnormalities were detected, report “see attachment” and attach the final report(s) for any other abnormalities detected.

Question 16: Were cytogenetics tested via karyotyping? (at diagnosis)

Specify if karyotyping studies were performed at diagnosis. Report Yes even if there were no evaluable metaphase cells / failed (these results will be specified below).

If karyotyping studies were not performed at diagnosis or it is unknown if performed, report No or Unknown, respectively.

Question 17: Results of tests

Specify if abnormalities were detected by karyotype at diagnosis.

If karyotyping failed or the sample was inadequate, select No evaluable metaphases.

*Submitting Karyotype Documentation
CIBMTR strongly encourages attaching the karyotype report when abnormalities are identified. For further instructions on how to attach documents in FormsNet3^SM, refer to the Training Guide.

Questions 18 – 21: Specify karyotype abnormalities (at diagnosis)

Report the ISCN compatible string, if applicable. Refer to Appendix C: Cytogenetics for more information on how to report using the ISCN functionality.

If the ISCN compatible string is not reported, then select the number of abnormalities detected by karyotype at diagnosis and select all abnormalities detected.

If a clonal abnormality is detected, but not listed as an option, select Other abnormality and specify the abnormality. If multiple other abnormalities were detected, report “see attachment” and attach the final report(s) for any other abnormalities detected.

*Molecular Marker Results
Questions capturing molecular marker results are intended to capture molecular abnormalities identified by molecular methods. Additional testing methods, such as FISH and chromosomal microarray, may identify molecular marker results but should not be reported in the molecular section(s) of the Disease Classification (2402) form. Abnormalities identified by karyotyping, FISH, or chromosomal microarray should only be reported in the cytogenetic section of the Disease Classification (2402) form.

*Submitting Molecular Marker Documentation
CIBMTR strongly encourages attaching the molecular report when abnormalities are identified. For further instructions on how to attach documents in FormsNet3^SM, refer to the Training Guide.

Questions 22 – 41: Specify molecular marker results (at diagnosis)

Molecular markers for disease refer to specific genetic sequences which are believed to be associated with the recipient’s primary disease. Testing for these sequences is often performed using PCR based methods. Once a marker has been identified, these methods can be repeated to detect minimal residual disease (MRD) in the recipient’s blood, marrow, or tissue. Molecular assessments include polymerase chain reaction (PCR) amplification to detect single specific disease markers; however, molecular methods are evolving and now include Sanger sequencing, and next generation sequencing (e.g., Illumina, Roche 454, Proton / PGM, SOLiD).

The molecular markers listed below are ELN AML markers and prognostic of AML. Due to the importance of these markers, it is necessary to know if the marker was positive, negative, or not assessed.

• ASXL1
• BCOR
• BCR::ABL1
• CEBPA
• DDX41
• EZH2
• FLT3-ITD
• GATA2
• NPM1
• RUNX1
• SF3B1
• SRSF2
• STAG2
• TP53
• U2AF1
• ZRSR2

For each molecular marker, specify if the marker was Positive or Negative at diagnosis and answer and additional questions. If the molecular marker was not assessed at diagnosis, select Not done.

If CEBPA was Positive, specify the CEBPA variant mutation and allelic expression. If the variant mutation is not documented, report the mutation as Unknown. If the allelic expression is not documented, confirm with the lab if this information can be determined prior to reporting Unknown.

If FLT3-ITD was Positive, specify the allelic ratio, if known. If there are multiple allelic ratios available for the at diagnosis time point, report the highest allelic ratio. If the allelic ratio is not documented, confirm with the lab if this information can be determined prior to reporting Unknown.

The allelic ratio data field is intended to capture the ratio of the FLT3-ITD mutation. This data field does not collect the allelic frequency; the allelic frequency is used to calculate the allelic ratio. The FLT-3 ITD allelic ratio (or signal ratio) compares the number of ITD-mutated alleles to the number of wild-type (normal) alleles. If the allele frequency was assessed, the ITD-mutated allele frequency will be documented on the molecular report; however, the wild-type allele frequency will need to be calculated. To determine the wild-type allele frequency, subtract the ITD-mutated allele frequency from 1 (or 100.0%). After determining the wild-type allele frequency, the allelic ratio can be assessed. To calculate the allelic ratio, divide the mutant allele frequency by the wild-type (normal) allele frequency. Review example 2 below for more information:

• Example 2:

• ITD variant allele frequency: 1.14% (0.0114)
  • As documented in the molecular report
• Wild-type allele frequency: 98.86% (0.9886)
  • Determined by subtraction 1.14% from 100.0%
• FLT3-ITD allelic ratio: 0.0114 / 0.9886 = 0.0115

Report the FLT3-ITD allelic ratio as 0.01

*Submitting Molecular Marker Documentation
CIBMTR strongly encourages attaching the molecular report when abnormalities are identified. For further instructions on how to attach documents in FormsNet3^SM, refer to the Training Guide.

Questions 42 – 43: Specify other positive molecular marker(s) identified (check all that apply)

Indicate if any other positive molecular markers (excluding the ELN AML molecular markers listed above), including variance of unknown significant markers, were detected at diagnosis.

If a molecular marker was detected, but not listed as an option, select Other molecular marker and specify the abnormality, along with the amino acid change, if known.

If molecular markers were not detected at diagnosis, the sample failed, testing was not completed or unknown if completed at diagnosis, report None. This option should also be selected if other molecular markers were tested and resulted as negative.

*In Between Diagnosis and Last Evaluation Assessment*s
Assessments performed at diagnosis, last evaluation and in between questions ask about testing performed at different time points prior to infusion. For reporting purposes, the in between time point is defined as any pre-infusion testing which cannot be reported as part of at diagnosis or last evaluation. For subsequent infusions, any testing performed after the prior infusion until the last evaluation for the current infusion should be reported here. For example, if relapse / progression occurred after the previous infusion but prior to last evaluation of the current infusion, report the relapse / progression abnormalities at the in between timepoint.

*In Between Diagnosis and Last Evaluation Assessments
Assessments performed at diagnosis, last evaluation and in between questions ask about testing performed at different time points prior to infusion. For reporting purposes, the in between time point is defined as any pre-infusion testing which cannot be reported as part of at diagnosis or last evaluation. For subsequent infusions, any testing performed after the prior infusion until the last evaluation for the current infusion should be reported here. For example, if relapse / progression occurred after the previous infusion but prior to last evaluation of the current infusion, report the relapse / progression abnormalities at the in between time point.

Question 44: Were cytogenetics tested (karyotyping or FISH)? (between diagnosis and last evaluation)

Cytogenetics is the study of chromosomes. Cytogenetic assessment involves testing blood or bone marrow for the presence of known chromosomal abnormalities that reflect the recipient’s disease.

Testing methods include conventional chromosome analysis (karyotyping) or fluorescence in situ hybridization (FISH). For more information about cytogenetic testing and terminology, see Appendix C: Cytogenetics.

Indicate if cytogenetic studies were performed between diagnosis and the last evaluation. If cytogenetic studies were not obtained at this time point or it is not known whether chromosome studies were performed, indicate No.

Question 45: Were cytogenetics tested via FISH? (between diagnosis and last evaluation)

Specify if FISH studies were performed between diagnosis and the last evaluation. If FISH studies were not performed at this time point, FISH sample was inadequate, the result ‘failed,’ or it is unknown if performed, report No.

Report chromosomal microarrays / chromosomal genomic arrays as FISH assessments.

Question 46: Results of tests

Specify if FISH abnormalities were identified between diagnosis and the last evaluation.

!International System for Human Cytogenetic Nomenclature (ISCN) for FISH
The International System for Human Cytogenetic Nomenclature (ISCN) compatible string is disabled for FISH and cannot be answered at this time.

*Submitting FISH Documentation
CIBMTR strongly encourages attaching the FISH report when abnormalities are identified. For further instructions on how to attach documents in FormsNet3^SM, refer to the Training Guide.

Questions 47 – 50: Specify FISH abnormalities (between diagnosis and last evaluation)

Report the ISCN compatible string, if the data field is enabled. If reporting the ISCN compatible string and multiple FISH assessments were completed between diagnosis and the last evaluation, add a separate instance of the ISCN compatible string to report each FISH ISCN compatible string.

Refer to Appendix C: Cytogenetics for more information on how to report using the ISCN functionality.

If the ISCN compatible string is not reported, then select the number of abnormalities detected by FISH between diagnosis and the last evaluation and select all abnormalities detected.

If a clonal abnormality is detected, but not listed as an option, select Other abnormality and specify the abnormality. If multiple other abnormalities were detected, report “see attachment” and attach the final report(s) for any other abnormalities detected.

Question 51: Were cytogenetics tested via karyotyping? (between diagnosis and last evaluation)

Specify if karyotyping studies were performed between diagnosis and the last evaluation. Report Yes even if there were no evaluable metaphase cells (these results will be specified below).

If karyotyping studies were not performed at this time point or it is unknown if performed, report No.

Question 52: Results of tests

Specify if abnormalities were detected by karyotype between diagnosis and the last evaluation.

If karyotyping failed or the sample was inadequate, select No evaluable metaphases.

*Submitting Karyotype Documentation
CIBMTR strongly encourages attaching the karyotype report when abnormalities are identified. For further instructions on how to attach documents in FormsNet3^SM, refer to the Training Guide.

Questions 53 – 56: Specify karyotype abnormalities (between diagnosis and last evaluation)

Report the ISCN compatible string, if applicable. If reporting the ISCN compatible string and multiple karyotype studies were completed between diagnosis and the last evaluation, add a separate instance of the ISCN compatible string to report each abnormal karyotype ISCN compatible string.

Refer to Appendix C: Cytogenetics for more information on how to report using the ISCN functionality.

If the ISCN compatible string is not reported, then select the number of abnormalities detected by karyotype between diagnosis and the last evaluation and select all abnormalities detected.

If a clonal abnormality is detected, but not listed as an option, select Other abnormality and specify the abnormality. If multiple other abnormalities were detected, report “see attachment” and attach the final report(s) for any other abnormalities detected.

*Molecular Marker Results
Questions capturing molecular marker results are intended to capture molecular abnormalities identified by molecular methods. Additional testing methods, such as FISH and chromosomal microarray, may identify molecular marker results but should not be reported in the molecular section(s) of the Disease Classification (2402) form. Abnormalities identified by karyotyping, FISH, or chromosomal microarray should only be reported in the cytogenetic section of the Disease Classification (2402) form.

*Submitting Molecular Marker Documentation
CIBMTR strongly encourages attaching the molecular report when abnormalities are identified. For further instructions on how to attach documents in FormsNet3^SM, refer to the Training Guide.

Questions 57 – 76: Specify molecular marker results (between diagnosis and last evaluation)

Molecular markers for disease refer to specific genetic sequences which are believed to be associated with the recipient’s primary disease. Testing for these sequences is often performed using PCR based methods. Once a marker has been identified, these methods can be repeated to detect minimal residual disease (MRD) in the recipient’s blood, marrow, or tissue. Molecular assessments include polymerase chain reaction (PCR) amplification to detect single specific disease markers; however, molecular methods are evolving and now include Sanger sequencing, and next generation sequencing (e.g., Illumina, Roche 454, Proton / PGM, SOLiD).

The molecular markers listed below are ELN AML markers and prognostic of AML. Due to the importance of these markers, it is necessary to know if the marker was positive, negative, or not assessed.

• ASXL1
• BCOR
• BCR::ABL1
• CEBPA
• DDX41
• EZH2
• FLT3-ITD
• GATA2
• NPM1
• RUNX1
• SF3B1
• SRSF2
• STAG2
• TP53
• U2AF1
• ZRSR2

For each molecular marker, specify if the marker was Positive or Negative between diagnosis and the last evaluation and answer additional questions. If the molecular marker was not assessed between diagnosis and the last evaluation, select Not done.

If CEBPA was Positive, specify the CEBPA variant mutation and allelic expression. If the variant mutation is not documented, report the mutation as Unknown. If the allelic expression is not documented, confirm with the lab if this information can be determined prior to reporting Unknown.

If FLT3-ITD was Positive, specify the allelic ratio, if known. If there are multiple allelic ratios available for the in between time point, report the lowest allelic ratio. If the allelic ratio is not documented, confirm with the lab if this information can be determined prior to reporting Unknown.

The allelic ratio data field is intended to capture the ratio of the FLT3-ITD mutation. This data field does not collect the allelic frequency; the allelic frequency is used to calculate the allelic ratio. The FLT-3 ITD allelic ratio (or signal ratio) compares the number of ITD-mutated alleles to the number of wild-type (normal) alleles. If the allele frequency was assessed, the ITD-mutated allele frequency will be documented on the molecular report; however, the wild-type allele frequency will need to be calculated. To determine the wild-type allele frequency, subtract the ITD-mutated allele frequency from 1 (or 100.0%). After determining the wild-type allele frequency, the allelic ratio can be assessed. To calculate the allelic ratio, divide the mutant allele frequency by the wild-type (normal) allele frequency. Review example 3 below for more information:

• Example 3:

• ITD variant allele frequency: 1.14% (0.0114)
  • As documented in the molecular report
• Wild-type allele frequency: 98.86% (0.9886)
  • Determined by subtraction 1.14% from 100.0%
• FLT3-ITD allelic ratio: 0.0114 / 0.9886 = 0.0115

Report the FLT3-ITD allelic ratio as 0.01

*Submitting Molecular Marker Documentation
CIBMTR strongly encourages attaching the molecular report when abnormalities are identified. For further instructions on how to attach documents in FormsNet3^SM, refer to the Training Guide.

Questions 77 – 78: Specify other positive molecular marker(s) identified (check all that apply)

Indicate if any other positive molecular markers (excluding the ELN AML molecular markers listed above), including variance of unknown significant markers, were detected between diagnosis and the last evaluation.

If a molecular marker was detected, but not listed as an option, select Other molecular marker and specify the abnormality, along with the amino acid change, if known.

If molecular markers were not detected between diagnosis and the last evaluation, the sample failed, testing was not completed or unknown if completed in between diagnosis and the last evaluation report, None. This option should also be selected if other molecular markers were tested and resulted as negative.

*Last Evaluation Assessments
Assessments performed at diagnosis, last evaluation and in between questions ask about testing performed at different time points prior to infusion. For reporting purposes, the last evaluation time point is defined as the most recent testing performed during the recipient’s work-up for infusion. Assessments performed during the last line of therapy or after the last line of therapy may be reported. If multiple assessments were performed, report the most recent. If additional therapy was given after the last assessment, do not report the test.

Question 79: Were cytogenetics tested (karyotyping or FISH)? (at last evaluation)

Cytogenetics is the study of chromosomes. Cytogenetic assessment involves testing blood or bone marrow for the presence of known chromosomal abnormalities that reflect the recipient’s disease.

Testing methods include conventional chromosome analysis (karyotyping) or fluorescence in situ hybridization (FISH). For more information about cytogenetic testing and terminology, see Appendix C: Cytogenetics.

Indicate if cytogenetic studies were at the last evaluation prior to the start of the preparative regimen / lymphodepleting therapy (or infusion if no preparative regimen / lymphodepleting therapy). If cytogenetic studies were not obtained at this time point or it is not known whether chromosome studies were performed, indicate No.

Question 80: Were cytogenetics tested via FISH? (at last evaluation)

Specify if FISH studies were performed at the last evaluation prior to the start of the preparative regimen / lymphodepleting therapy (or infusion if no preparative regimen / lymphodepleting therapy). If FISH studies were not performed at this time point, FISH sample was inadequate, the result ‘failed,’ or it is unknown if performed, report No.

Report chromosomal microarrays / chromosomal genomic arrays as FISH assessments.

Question 81: Results of tests

Specify if FISH abnormalities were identified at the last evaluation prior to the preparative regimen / lymphodepleting therapy (or infusion if no preparative regimen / lymphodepleting therapy).

!International System for Human Cytogenetic Nomenclature (ISCN) for FISH
The International System for Human Cytogenetic Nomenclature (ISCN) compatible string is disabled for FISH and cannot be answered at this time.

*Submitting FISH Documentation
CIBMTR strongly encourages attaching the FISH report when abnormalities are identified. For further instructions on how to attach documents in FormsNet3^SM, refer to the Training Guide.

Questions 82 – 85: Specify FISH abnormalities (at last evaluation)

Report the ISCN compatible string, if the data field is enabled.

Refer to Appendix C: Cytogenetics for more information on how to report using the ISCN functionality.

If the ISCN compatible string is not reported, then select the number of abnormalities detected by FISH last evaluation and select all abnormalities detected.

If a clonal abnormality is detected, but not listed as an option, select Other abnormality and specify the abnormality. If multiple other abnormalities were detected, report “see attachment” and attach the final report(s) for any other abnormalities detected.

Question 86: Were cytogenetics tested via karyotyping? (at last evaluation)

Specify if karyotyping studies were performed at the last evaluation prior to the preparative regimen / lymphodepleting therapy (or infusion if no preparative regimen / lymphodepleting therapy). Report Yes even if there were no evaluable metaphase cells (these results will be specified below).

If karyotyping studies were not performed at this time point or it is unknown if performed, report No.

Question 87: Results of tests

Specify if abnormalities were detected by karyotype at the last evaluation prior to the preparative regimen / lymphodepleting therapy (or infusion if no preparative regimen / lymphodepleting therapy)

If karyotyping failed or the sample was inadequate, select No evaluable metaphases.

*Submitting Karyotype Documentation
CIBMTR strongly encourages attaching the karyotype report when abnormalities are identified. For further instructions on how to attach documents in FormsNet3^SM, refer to the Training Guide.

Questions 88 – 91: Specify karyotype abnormalities (at last evaluation)

Report the ISCN compatible string, if applicable. Refer to Appendix C: Cytogenetics for more information on how to report using the ISCN functionality.

If the ISCN compatible string is not reported, then select the number of abnormalities detected at the last evaluation prior to the start of the preparative regimen / lymphodepleting therapy (or infusion if no preparative regimen / lymphodepleting therapy) and select all abnormalities detected.

If a clonal abnormality is detected, but not listed as an option, select Other abnormality and specify the abnormality. If multiple other abnormalities were detected, report “see attachment” and attach the final report(s) for any other abnormalities detected.

*Molecular Marker Results
Questions capturing molecular marker results are intended to capture molecular abnormalities identified by molecular methods. Additional testing methods, such as FISH and chromosomal microarray, may identify molecular marker results but should not be reported in the molecular section(s) of the Disease Classification (2402) form. Abnormalities identified by karyotyping, FISH, or chromosomal microarray should only be reported in the cytogenetic section of the Disease Classification (2402) form.

*Submitting Molecular Marker Documentation
CIBMTR strongly encourages attaching the molecular report when abnormalities are identified. For further instructions on how to attach documents in FormsNet3^SM, refer to the Training Guide.

Questions 92 – 111: Specify molecular marker results (at last evaluation)

Molecular markers for disease refer to specific genetic sequences which are believed to be associated with the recipient’s primary disease. Testing for these sequences is often performed using PCR based methods. Once a marker has been identified, these methods can be repeated to detect minimal residual disease (MRD) in the recipient’s blood, marrow, or tissue. Molecular assessments include polymerase chain reaction (PCR) amplification to detect single specific disease markers; however, molecular methods are evolving and now include Sanger sequencing, and next generation sequencing (e.g., Illumina, Roche 454, Proton / PGM, SOLiD).

The molecular markers listed below are ELN AML markers and prognostic of AML. Due to the importance of these markers, it is necessary to know if the marker was positive, negative, or not assessed.

• ASXL1
• BCOR
• BCR::ABL1
• CEBPA
• DDX41
• EZH2
• FLT3-ITD
• GATA2
• NPM1
• RUNX1
• SF3B1
• SRSF2
• STAG2
• TP53
• U2AF1
• ZRSR2

For each molecular marker, specify if the marker was Positive or Negative at the last evaluation and answer additional questions. If the molecular marker was not assessed at the last evaluation, select Not done.

If CEBPA was Positive, specify the CEBPA variant mutation and allelic expression. If the variant mutation is not documented, report the mutation as Unknown. If the allelic expression is not documented, confirm with the lab if this information can be determined prior to reporting Unknown.

If FLT3-ITD was Positive, specify the allelic ratio at the last evaluation, if known. If the allelic ratio is not documented, confirm with the lab if this information can be determined prior to reporting Unknown.

The allelic ratio data field is intended to capture the ratio of the FLT3-ITD mutation. This data field does not collect the allelic frequency, the allelic frequency is used to calculate the allelic ratio. The FLT-3 ITD allelic ratio (or signal ratio) compares the number of ITD-mutated alleles to the number of wild-type (normal) alleles. If the allele frequency was assessed, the ITD-mutated allele frequency will be documented on the molecular report; however, the wild-type allele frequency will need to be calculated. To determine the wild-type allele frequency, subtract the ITD-mutated allele frequency from 1 (or 100.0%). After determining the wild-type allele frequency, the allelic ratio can be assessed. To calculate the allelic ratio, divide the mutant allele frequency by the wild-type (normal) allele frequency. Review example 4 below for more information:

• Example 4:

• ITD variant allele frequency: 1.14% (0.0114)
  • As documented in the molecular report
• Wild-type allele frequency: 98.86% (0.9886)
  • Determined by subtraction 1.14% from 100.0%
• FLT3-ITD allelic ratio: 0.0114 / 0.9886 = 0.0115

Report the FLT3-ITD allelic ratio as 0.01

*Submitting Molecular Marker Documentation
CIBMTR strongly encourages attaching the molecular report when abnormalities are identified. For further instructions on how to attach documents in FormsNet3^SM, refer to the Training Guide.

Questions 112 – 113: Specify other positive molecular marker(s) identified (check all that apply)

Indicate if any other positive molecular markers (excluding the ELN AML molecular markers listed above), including variance of unknown significant markers, were detected at the last evaluation.

If a molecular marker was detected, but not listed as an option, select Other molecular marker and specify the abnormality, along with the amino acid change, if known.

If molecular markers were not detected at the last evaluation, the sample failed, testing was not completed or unknown if completed at last evaluation, report None. This option should also be selected if other molecular markers were tested and resulted as negative.

Question 114: Did the recipient have central nervous system leukemia at any time prior to the start of the preparative regimen / infusion?

Central nervous system (CNS) involvement by leukemia may be detected via pathologic examination of cerebrospinal fluid or tumor tissue as well as by radiological examinations (e.g., MRI, PET/CT, MIBG, etc.).

Specify if the recipient had documented involvement of AML in the CNS at any time prior to the start of the preparative regimen / lymphodepleting therapy (or infusion if no preparative regimen / lymphodepleting therapy).

If all CNS testing was negative since the time of diagnosis, report No.

If testing for CNS involvement was not performed from the time of diagnosis to the time of infusion, report Unknown.

Question 115: What was the disease status (based on hematologic test results)?

This data field is intended to capture the pre-infusion disease status, based on clinical / hematologic and / or radiologic (if applicable) assessments. Refer to the AML Response Criteria section for definitions of each response. For reporting purposes, consider complete remission with incomplete hematologic recovery (CRi) as complete remission (CR1, CR2, or CR3+).

If the recipient did not receive any treatment for AML from the time of diagnosis to the start of the preparative regimen (or infusion if no preparative regimen), report No treatment.

*Number of Induction Cycles
The intent of this question is to capture the number of induction cycles required to achieve the first CR (including CRi) in the recipient’s disease history, regardless of if there have been prior relapses or infusions.

Question 116: How many cycles of induction therapy were required to achieve 1st complete remission (CR)? (includes CRi)

Chemotherapy is initially given as induction therapy intended to bring the disease into remission. Recipients usually have one to two cycles of induction therapy; disease prognosis is considered less favorable if the patient fails to achieve remission with the first induction therapy and even poorer if patients fail two or more induction therapies.¹ An example of a common induction therapy for all AML subtypes (except M3) is a combination of an anthracycline and cytarabine, commonly known as “7+3.” In this regimen, cytarabine is typically administered for seven days at a dose of 100 mg/m²/day. The anthracycline (usually daunorubicin at 45 to 60 mg/m²/day or idarubicin at 12 mg/m²/day) is generally given on the first three days the cytarabine is given.

The second phase of chemotherapy is known as consolidation therapy. The goal of consolidation therapy is to destroy any remaining leukemia cells and sustain remission. An example of a common consolidation therapy for all AML subtypes (except M3) is high-dose cytarabine, commonly referred to as “HiDAC.” In this regimen, cytarabine is typically administered at a dose exceeding 10 g/m² per cycle.

Maintenance chemotherapy may follow consolidation therapy. Maintenance chemotherapy is given in lower doses and is intended to prolong a remission. Maintenance therapy is used less commonly for the treatment of AML than other malignancies. Treatment may also be administered for relapsed disease. Much like induction therapy, treatment for relapse is intended to bring the disease back into remission. Systemic therapeutic agents used to induce remission following relapse often differ from those used in the initial induction, since the disease is often resistant to many of the agents used earlier in the disease course and is considered high-risk with a poor prognosis. Allogeneic HCT is often considered the only potential “cure” for relapsed disease.

If the pre-infusion disease status is CR1, report the number of cycles of induction therapy that were required to achieve the first clinical / hematologic CR.

¹ Ravandi F, Cortes J, Faderl S, et al. (2010). Characteristics and outcome of patients with acute myeloid leukemia refractory to one cycle of high-dose cytarabine-based induction therapy. Blood, 116(26):5818-23.

Question 117: Date CR first achieved

This question is intended to capture the date when the first clinical / hematologic CR was achieved.

Report the date when the first CR was achieved. This should be the earliest date all international working group criteria for CR have been met. Report the date the sample was collected for pathologic evaluation (i.e., bone marrow biopsy) or blood / serum assessments (i.e., CBC, peripheral blood smear).

If only CRi was achieved (which is reported as CR), report the first date when the CRi criteria was met.

If the exact date is not known, use the process for reporting partial or unknown dates as described in General Instructions, General Guidelines for Completing Forms.

Question 118: Date of most recent relapse

Enter the date of the most recent relapse prior to the start of the preparative regimen / lymphodepleting therapy (or infusion if no preparative regimen / lymphodepleting therapy). If reporting a pathological evaluation (i.e., bone marrow) or blood / serum assessment (i.e., CBC, peripheral blood smear), enter the date the sample was collected.

If extramedullary disease was detected by radiographic examination (i.e.., X-ray, CT scan, MRI scan, PET scan), enter the date the imaging took place.

If the physician determines evidence of relapse following a clinical assessment during an office visit, report the date of assessment.

If the exact date is not known, use the process for reporting partial or unknown dates as described in General Instructions, General Guidelines for Completing Forms.

Question 119: Specify method(s) that was used to assess measurable residual disease status (check all that apply) (at infusion)

Specify the method(s) how the measurable residual status was assessed at the last evaluation prior to the preparative regimen / lymphodepleting therapy (or infusion if no preparative regimen / lymphodepleting therapy). Select all that apply.

• FISH: A sensitive technique that assesses a large number of cells. This technique uses special probes that recognize and bind to fragments of DNA. These probes are mixed with cells from the recipient’s blood or bone marrow. A fluorescent “tag” is then used to visualize the binding of the probe to the diseased cells.
• Karyotype: A technique performed by culturing cells (growing cells under controlled conditions) until they reach the dividing phase. Techniques are then performed to visualize the chromosomes during cell division so that various bands and reconfigurations can be seen. Banding pattern differentiation and chromosomal reconfiguration demonstrate evidence of disease.
• Flow cytometry: A method of analyzing peripheral blood, bone marrow, or tissue preparations for multiple unique cell characteristics. Its primary clinical purpose in the setting of leukemias is to quantify blasts in the peripheral blood or bone marrow, or to identify unique cell populations through immunophenotyping. Flow cytometry assessment may also be referred to as “MRD,” or minimal residual disease, testing.
• PCR: Polymerase chain reaction (PCR) amplification is a molecular assessment used to detect single specific disease markers. Testing for molecular markers is often performed using PCR based methods. Once a marker has been identified, this method can be repeated to detect minimal residual disease (MRD) in the recipient’s blood, marrow, or tissue.
• NGS: Next-generation sequencing (NGS), also known as massive parallel sequencing, is another molecular assessment which is used to determine the order of nucleotides in a genome. If the method was ClonoSEQ, also select this option.

If testing for measurable residual status was not completed at the last evaluation, select Not assessed.

Question 120: Was measurable residual disease detected by FISH? (at infusion)

Indicate if measurable residual disease was detected by FISH at the last evaluation prior to the preparative regimen / lymphodepleting therapy (or infusion if no preparative regimen / lymphodepleting therapy).

If the results are not clear, seek physician clarification to determine if measurable residual disease was detected by FISH at the last evaluation.

Question 121: Was measurable residual disease detected by karyotyping assay? (at infusion)

Indicate if measurable residual disease was detected by karyotype at the last evaluation prior to the preparative regimen / lymphodepleting therapy (or infusion if no preparative regimen / lymphodepleting therapy).

If the results are not clear, seek physician clarification to determine if minimal residual disease was detected by karyotype at the last evaluation.

Question 122: Was measurable residual disease detected by flow cytometry? (at infusion)

Indicate if measurable residual disease was detected by flow cytometry at the last evaluation prior to the preparative regimen / lymphodepleting therapy (or infusion if no preparative regimen / lymphodepleting therapy).

If the results are not clear, seek physician clarification to determine if minimal residual disease was detected by flow cytometry at the last evaluation.

!Original vs Aberrant Phenotype
The original vs aberrant phenotype questions are currently disabled.

Questions 123 – 125: Which leukemia phenotype was used for detection? (at infusion) (check all that apply)

Specify which leukemia phenotype was used for detection. Select all that apply.

If the Original leukemia immunophenotype was used, specify the lower limit of detection, and then indicate if measurable residual disease was detected by flow cytometry at the last evaluation prior to the start of the preparative regimen / lymphodepleting therapy (or infusion if no preparative regimen / lymphodepleting therapy).

If an Aberrant phenotype was used, specify the lower limit of detection, and then indicate if measurable residual disease was detected by flow cytometry at the last evaluation prior to the start of the preparative regimen / lymphodepleting therapy (or infusion if no preparative regimen / lymphodepleting therapy).

If the results are not clear, seek physician clarification to determine if minimal residual disease was detected by flow cytometry at the last evaluation.

Question 126: Was measurable residual disease detected by PCR? (at infusion)

Indicate if measurable residual disease was detected by PCR at the last evaluation prior to the start of the preparative regimen / lymphodepleting therapy (or infusion if no preparative regimen / lymphodepleting therapy).

If the results are not clear, seek physician clarification to determine if measurable residual disease was detected by PCR at the last evaluation assay at the last evaluation prior to the start of the preparative regimen / lymphodepleting therapy (or infusion if no preparative regimen / lymphodepleting therapy).

Question 127: Was measurable residual disease detected by NGS? (at infusion)

Indicate if measurable residual disease was detected by NGS at the last evaluation prior to the start of the preparative regimen / lymphodepleting therapy (or infusion if no preparative regimen / lymphodepleting therapy).

If the results are not clear, seek physician clarification to determine if measurable residual disease was detected by NGS at the last evaluation assay at the last evaluation prior to the start of the preparative regimen / lymphodepleting therapy (or infusion if no preparative regimen / lymphodepleting therapy).

Section Updates:

Question Number	Date of Change	Add/Remove/Modify	Description	Reasoning (If applicable)
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