The CLL Study Performa
Name
Hospital Record ID(File No.)*:
Date of Birth:
Gender:
Male
Female
Ethnicity
Select
Punjabi
Sindi
Pashtun
Muhajirs
Kashmiri
Balochi
Balti
Other
Province
Federal Capital
Punjab
Sindh
Balouchistan
Azad Kashmir
Gilgit Baltistan
Khyber Pakhtunkhwa
Address
Wealth Status
Fully insured-entitled
Out of pocket
Sponsored(charity/zakat)
Socioeconomic Status:
Select
Limited
Enhanced
Restricted
Frailty Index
Select
1
2
3
4
5
Hospital Name:
AFBMTC
AECH
AKUH
Cancer Care Clinic National Hospital FSD
CMH Multan
Hameed Latif
INMOL
JMPC
Mayo
Noori
PTPP
SKMC
Sheikh Zadhid RahimyarKhan
Other
Phone No:
Phone No. 2:
Date Of Diagnosis:
CNIC
Height (cm)
Weight(kg)
Family History of Haem Malignancy
Yes
No
Unknown
Smoking
Yes
No
Unknown
Alcohal
Yes
No
Unknown
Comorbidities:
Yes
No
if yes please specify:
active malignancy
past malignancy
Neurological disorder
Cardiovascular disorder
Hypertension
Diabetes
Chronic liver disease
Chronic renal disease
Autoimmune disorders
Other:
ECOG:
0-Asymptomatic
1-Symptomatic but completely ambulatory
2-Symptomatic, less then 50% in bed during the day
3-Symptomatic greater then 50% in bed but not bedbound
4-Bedbound
N/A
Incidental Presentation:
Yes
No
Clinical Presentation:
Asymptomatic
Lethargy
Lymph Node Swelling
SOB
Weight loss
Recurrent Infection
Bleeding
Other:
Examination findings:
Cervical LN
Select
Yes
No
Unknown
Axillary LN
Select
Yes
No
Unknown
Inguinal LN
Select
Yes
No
Unknown
Liver
Select
Yes
No
Unknown
Spleen
Select
Yes
No
Unknown
Other:
Hematological Data
Date Of laboratory analysis:
Hemoglobin (g/dl)
WBC (x 109/L)
Platelets(x109/L)
ALC x 10(9)/l
Retic count(%)
Binet Stage
Select
Binet A
Binet B
Binet C
RAI-Stage
Select
0
1
2
3
4
BMA
Select
Done
Not Done
Unknown
BMA findings
Trephine
Select
Done
Not Done
Unknown
Trephine findings
Reticulin
Select
0
1
2
3
Unknown
Immunophenotyping
CD5
Select
Positive
Negative
Unknown
CD23
Select
Positive
Negative
Unknown
CD20
Select
Positive
Negative
Unknown
CD79b
Select
Positive
Negative
Unknown
FMC7
Select
Positive
Negative
Unknown
sIgG
Select
Positive
Negative
Unknown
Risk Staging
CD38
Select
Positive
Negative
Unknown
Zap70
Select
Positive
Negative
Unknown
del 17p
Select
Positive
Negative
Unknown
11q23
Select
Positive
Negative
Unknown
13q14
Select
Positive
Negative
Unknown
trisomy 12
Select
Positive
Negative
Unknown
TP53 mutation
Select
Positive
Negative
Unknown
IgHV mutation
Select
Positive
Negative
Unknown
Other Investigations
Coombs test:
Select
Positive
Negative
Unknown
LDH
Select
Normal
Raised
Unknown
Serum Creatinine
Select
Normal
Raised
Unknown
B2 microglobulin
Select
Normal
Raised
Unknown
serum Albumin
Select
Normal
Raised
Unknown
EBV PCR
Select
Normal
Raised
Unknown
HIV
Select
Positive
Negative
Unknown
HbsAg
Select
Positive
Negative
Unknown
Anti-HCV
Select
Positive
Negative
Unknown
Radiology findings CT
Radiology findings PET
Echo
Select
Done
Not Done
Unknown
Echo findings
Prior Malignancy:
Yes
No
SPEP
Select
Positive
Negative
Unknown
At diagnosis Indication of treatment as per iwCLL:
Select
Yes
No
Unknown
Mention the indication (if applicable)
Observation initially after diagnosis:
Select
Yes
No
Unknown
Time to treat after initial observation period (months)
First Line Treatment
First Line Treatment:
Select
BR
FCR
Chlorambucil +- prednsiolone
Ven
ibrutinib
Other
Date of first line treatment
Dose of first line treatment
Number of cycles of first line/ duration
Response to First Line Treatment:
Select
CR
PR
SD
PD
Hematological Remission
Modular Partial
Not Available
Response modality:
Select
BM
CT
PET
Clinical
Molecualr
Complications of first line treatment
Duration of response first line ( time from start of treatment to need for next line )
Second Line Treatment
Second Line Treatment:
Date of Second line treatment
Indication of Second line treatment
Dose of Second line treatment
Number of cycles of Second line/ duration
Response to Second Line Treatment:
Select
CR
PR
SD
PD
Hematological Remission
Modular Partial
Not Available
Complications of Second line treatment
Duration of response Second line ( time from start of treatment to need for next line )
Third Line Treatment
Third Line Treatment:
Date of Third line treatment
Indication of Third line treatment
Dose of Third line treatment
Number of cycles of Third line/ duration
Response to Third Line Treatment:
Select
CR
PR
SD
PD
Hematological Remission
Modular Partial
Not Available
Complications of Third line treatment
Duration of response Third line ( time from start of treatment to need for next line )
Other Line and Beyond Treatment
Other Line Treatment:
Novel Line Treatment
Novel therapy (BTKi/BCL-2 inhibitors used):
Select
Yes
No
Unknown
Type of Novel Therapy
Novel Therapy
Date of Novel line treatment
Dose of Novel Therapy
Dose Reduction Novel therapy:
Select
Yes
No
Response to Novel Therapy:
Select
CR
PR
SD
PD
Hematological Remission
Modular Partial
Not Available
Complications of Novel line treatment
Duration of Novel Therapy
Total Lines of Therapy
Select
1
2
3
4
5
more than 5
Richter transformation
Select
Yes
No
Type of Richter transformation
Select
DLBCL
HL
Other
HSCT
Select
Yes
No
Unknown
Type of HSCT
Select
Auto HCT
Allo
Unknown
HSCT conditioning
Select
MAC
RIC
Donor Type
Select
Matched Related
Haplo
Auto
Graft source
Select
Bone Merrow
PBSC
BM+PBSC
CD34 dose(10^6/ltr)
Graft failure
Select
Yes
No
Unknown
aGVHD
Select
Yes
No
Unknown
cGVHD
Select
Yes
No
Unknown
Last follow-up(date)
Survival Status
Select
aLive
Dead
lost to follow-up
Date of Death
Cause of Death
Disease status at last follow-up
Select
SD
PD
CR
PR
Hematological Remission
Modular Partial
Relapsed
lost to follow-up
DFS Status
Select
Yes
No
Unknown
OS (months)
DFS (months)
Submitted by:
Name:
Email:
Phone No:
Institute/Organization:
Supervised by:
Supervisor's Name:
Supervisor's Email:
Supervisor's Phone No:
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