HAEMATOPOIETIC STEM CELL TRANSPLANTATION (HSCT) REFERRAL FORM
Department of Haematology, Ampang Hospital, Selangor.
Name of patient
*
IC
*
Please include "-"
RN
Age
*
Sex
*
Male
Female
Race
*
Bumiputera Sabah
Bumiputera Sarawak
Chinese
Foreigner
Indian
Malay
Other
Orang Asli Semenanjung
Sikh
Siamese Malaysia
Phone Number
*
Other Phone Number
Blood Group
A
AB
B
O
Unknown
Rh
Positive
Negative
Unknown
Hep B
Yes
No
Hep C
Yes
No
HIV
Yes
No
BMI
Diagnosis
*
Other
Date Diagnosed
*
-
Day
-
Month
Year
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AML/ALL
Acute Leukaemia
*
AML
ALL/LBL
Biphenotypic
*
Yes
No
Type (AML)
*
De Novo
Secondary
Cell Type (ALL/LBL)
*
B Cell
T Cell
Unknown
WHO - Myeloid
*
WHO - Lymphoid
*
Hb
Platelet
WBC
*
Cytogenetics
*
Normal karyotype
Complex karyotype
NOT DONE
NOT AVAILABLE
SHORT SPREAD
Hyperdiploidy
Hypodiploidy
t(1;19)
t(3;3)
t(3q)
t(4;11)
t(4;14)
t(5;17)
t(6;9)
t(6;11)
t(6;14)
t(8;14)
t(8;21)
t(9;11)
t(9;22)
t(10;11)
t(11;14)
t(11;17)
t(11;19)
t(12;21)
t(14;16)
t(14;20)
t(15;17)
t(16;16)
t(v,11q)
+12
+19
+8
-7
−Y
del(3q)
del(5q)
del(6q)
del(7q)
del(9p)
del(9q)
del(11q)
del(12p)
del(13q)
del(17p)
del(20q)
I(17q)
inv(3)
Inv(3q)
inv(16)
Monosomy 13
Monosomy 14
Monosomy 16
Monosomy 17
OTHER
Detail (Cytogenetics)
Molecular
*
Normal
NOT DONE
NOT AVAILABLE
AFF1(AF4)-MLL
ASXL1
BCR-ABL1
CBFB-MYH11
CEBPA mutation
c-KIT
DEK-NUP214
DNMT3A
ELL-MLL
FLT3-ITD
IKZF1 (IKAROS)
IL3-IGH
MLL-PTD
MLLT1(ENL)-MLL
MLLT10(AF10)-MLL
MLLT3(AF9)-MLL
MLLT4(AF6)-MLL
Other MLL-rearrangement
NOTCH1 & FBXW7
NPM1 mutation
PML-RARα
RBM15-MKL1
RPN1-EVI1
RUNX1
RUNX1/RUNXT1
TCF3-PBX1
TEL(ETV6)-AML1(RUNX1)
TP53
OTHER
Detail (Molecular)
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CML
Phase at Diagnosis
*
1st Chronic
> 1st Chronic
Accelerated
Blast
Unknown
Pending
Splenomegaly
*
Yes
No
Unknown
Pending
Hb
*
Platelet
*
WBC
*
Basophilia >20%
*
Yes
No
Unknown
Cytogenetics
*
Normal karyotype
Complex karyotype
NOT DONE
NOT AVAILABLE
SHORT SPREAD
Hyperdiploidy
Hypodiploidy
t(1;19)
t(3;3)
t(3q)
t(4;11)
t(4;14)
t(5;17)
t(6;9)
t(6;11)
t(6;14)
t(8;14)
t(8;21)
t(9;11)
t(9;22)
t(10;11)
t(11;14)
t(11;17)
t(11;19)
t(12;21)
t(14;16)
t(14;20)
t(15;17)
t(16;16)
t(v,11q)
+12
+19
+8
-7
−Y
del(3q)
del(5q)
del(6q)
del(7q)
del(9p)
del(9q)
del(11q)
del(12p)
del(13q)
del(17p)
del(20q)
I(17q)
inv(3)
Inv(3q)
inv(16)
Monosomy 13
Monosomy 14
Monosomy 16
Monosomy 17
OTHER
Detail (Cytogenetics)
Transfromed
Transformed Date
-
Day
-
Month
Year
Date
Transformed into
Memo
BCR-ABL TKD Mutation
D276G
E255K
E355G
F317L
F359V
G250E
H396P
L387F
M244V
M351T
T315I
V379I
Y253H
Negative for T315I
Not mutation detected
Tyrosine Kinase Inhibitor (TKI) given:
*
Yes
No
TKI
Imatinib
Nilotinib
Bosutinib
Ponatinib
Other TKI
Other TKI
Imatinib
Nilotinib
Bosutinib
Ponatinib
Other TKI
Reason for HSCT (may choose >1)
*
Advanced phase
Imatinib resistance
Dasatinib resistance
Nilotinib resistance
Clonal evolution
Poor risk patient or high risk CML (e.g. Sokal > 1.2)
ABL mutation
Standard indication at diagnosis
No engraftment after allo BMT
Clinical study
Other
Other reason
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Lymphoma
Cell Type
*
NHL (B-cell)
NHL (T-cell and NK cell)
Hodgkins
Unknown
Mature B-cell Neoplasms
*
Chronic lymphocytic leukemia/small lymphocytic lymphoma
Monoclonal B-cell lymphocytosis
B-cell prolymphocytic leukemia
Splenic marginal zone lymphoma
Hairy cell leukaemia
Extranodal marginal zone lymphoma of mucosa associated lymphoid tissue (MALT)
Nodal marginal zone lymphoma
Lymphoplasmacytic lymphoma (LPL) / Waldenstrom macroglobulinaemia
Follicular lymphoma
Mantle cell lymphoma
Diffuse large B-cell lymphoma (DLBCL), (NOS)
T-cell/hystiocyte rich large B cell lymphoma
Primary DLBCL of the CNS
Primary cutaneous DLBCL, leg type
EBV positive DLBCL of the elderly
DLBCL associated with chronic inflammation
Lymphomatoid granulomatosis
Primary mediastinal (thymic) large B-cell lymphoma
Intravascular large B-cell lymphoma
ALK positive large B-cell lymphoma
Plasmablastic lymphoma
Large B-cell lymphoma arising in HHV8- associated multicentric Castleman disease
Primary effusion lymphoma (PEL)
Burkitt lymphoma (BL)
High-grade B-cell lymphoma, NOS
High-grade B-cell lymphoma, with MYC and BCL2 and/or BCL6 rearrangements
B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma and classical Hodgkin lymphoma (Intermediate DLBCL/HD)
Other B-cell
Other B-Cell
Mature T-cell & NK-cell Neoplasms
*
T-cell prolymphocytic leukemia
T-cell large granular lymphocytic leukaemia
Aggressive NK-cell leukaemia
Systemic EBV positive T-cell lymphoproliferative disease of childhood
Hydroa vacciniforme-like lymphoma
Adult T-cell leukaemia/lymphoma
Extranodal NK/T-cell lymphoma, nasal type
Enteropathy-associated T-cell lymphoma
Hepatosplenic T-cell lymphoma
Subcutaneous panniculitis-like T-cell lymphoma
Mycosis fungoides (MF)
Sézary syndrome
Lymphomatoid papulosis
Primary cutaneous anaplastic large cell lymphoma
Primary cutaneous gamma-delta T-cell lymphoma
Primary cutaneous CD8 positive aggressive epidermotropic cytotoxic T-cell lymphoma
Primary cutaneous CD4 positive small/medium T-cell lymphoma
Peripheral T-cell lymphoma, NOS (PTCL)
Angioimmunoblastic T-cell lymphoma
Anaplastic large-cell lymphoma (ALCL), ALK-positive
Anaplastic large-cell lymphoma (ALCL), ALK-negative
Other T-cell
Other T-Cell
Hodgkin Lymphoma
*
Stage at Diagnosis
I
IE
II
IIE
III
IIIE
IIIS
IV
Unknown
B Symptom
Yes
No
Unknown
Bulky >10cm
Yes
No
Unknown
Rai Stage (CLL/SLL)
I
II
III
IV
Not evaluated
Binet Stage (CLL/SLL)
A
B
C
Not evaluated
International Prognostic Scoring System for Waldenström’s Macroglobulinemia (ISSWM)
Low risk (0-1 score points except age >65)
Intermediate risk (score 2 or age >65 alone)
High risk (3-5)
Not evaluated
FL Grading
Grade I
Grade II
Grade III
Not evaluated
FLIPI
Low risk
Intermediate risk
High risk
Not evaluated
MCL Grading
indolent
classicaI
pleomorphic
blastoid
Not evaluated
MIPI
Low risk
Intermediate risk
High risk
Not evaluated
IPI
Low risk (0-1 score points)
Low-Intermediate risk (2)
High-intermediate risk
High risk (4 or 5)
Not evaluated
ISCL/EORTC
IA
IB
IIA
IIB
IIIA
IIIB
IVA1
IVA2
IVB
Not evaluated
IPS Score for HL
Good risk (IPS 0-1)
Fair risk (IPS 2-3)
Poor risk (IPS 4-7)
Not evaluated
Any cytogenetics and molecular abnormalities?
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Myeloma/Plasma Cell Disorder
Sub-classification
*
Multiple myeloma- Heavy chain and light chain
Multiple myeloma- Light chain only
Multiple myeloma- Non secretory
Plasma Cell Leukaemia
Solitary plasmacytoma of bone
POEMS
Monoclonal light and heavy chain deposition disease (LCDD/HCDD)
Other
Heavy Chain
IgG
IgA
IgM
IgD
IgE
None
Unknown
Pending
Light Chain
Lambda
Kappa
None
Unknown
Pending
Hb
Platelet
WBC
B2 microglobulin high (>3.5)
Yes
No
Unknown
Renal impaired (creat >150)
Yes
No
Unknown
High Calcium >2.6
Yes
No
Unknown
High LDH
Yes
No
Unknown
Poor performance
Yes
No
Unknown
Low albumin
Yes
No
Unknown
Cytogenetics
Normal karyotype
Complex karyotype
NOT DONE
NOT AVAILABLE
SHORT SPREAD
Hyperdiploidy
Hypodiploidy
t(1;19)
t(3;3)
t(3q)
t(4;11)
t(4;14)
t(5;17)
t(6;9)
t(6;11)
t(6;14)
t(8;14)
t(8;21)
t(9;11)
t(9;22)
t(10;11)
t(11;14)
t(11;17)
t(11;19)
t(12;21)
t(14;16)
t(14;20)
t(15;17)
t(16;16)
t(v,11q)
+12
+19
+8
-7
−Y
del(3q)
del(5q)
del(6q)
del(7q)
del(9p)
del(9q)
del(11q)
del(12p)
del(13q)
del(17p)
del(20q)
I(17q)
inv(3)
Inv(3q)
inv(16)
Monosomy 13
Monosomy 14
Monosomy 16
Monosomy 17
OTHER
Detail (Cytogenetics)
Memo
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Solid Tumour
Sub-classification
*
Bone sarcoma (excluding Ewing sarcoma/PNET)
Breast
Central nervous system tumours (include CNS PNET)
Colorectal
Ewing sarcoma (ES)/PNET, extra-skeletal
Ewing sarcoma (ES)/PNET, skeletal
Germ cell tumour, extragonadal only
Germ cell tumour, gonadal
Head and neck
Hepatobiliary
Kidney cancer excluding Wilm’s tumour
Lung cancer, non-small cell
Lung cancer, small cell
Medulloblastoma
Melanoma
Neuroblastoma
Ovarian (carcinoma)
Pancreatic
Prostate
Renal cell
Retinoblastoma
Rhabdomyosarcoma
Soft tissue sarcoma (excluding Rhabdo and extra-skeletal ES)
Thymoma
Wilm’s tumour
Other
Other
Histological grading
1
2
3
4
Not evaluated
Unknwon
TNM classification
Tumour
0
1
2
3
4
X
Not evaluated
Unknown
Nodes
0
1
2
3
X
Not evaluated
Unknown
Metastases*
0
1
X
Not evaluated
Unknown
*For metastases, 0 indicates “No metastasis”, 1 indicates “Metastasis” and X indicates “Not evaluable”
Disease-specific staging
Stage
I
II
III
IV
Not evaluated
Unknown
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MDS
WHO - Myeloid
*
Hb
Platelet
WBC
Cytogenetics
*
Normal karyotype
Complex karyotype
NOT DONE
NOT AVAILABLE
SHORT SPREAD
Hyperdiploidy
Hypodiploidy
t(1;19)
t(3;3)
t(3q)
t(4;11)
t(4;14)
t(5;17)
t(6;9)
t(6;11)
t(6;14)
t(8;14)
t(8;21)
t(9;11)
t(9;22)
t(10;11)
t(11;14)
t(11;17)
t(11;19)
t(12;21)
t(14;16)
t(14;20)
t(15;17)
t(16;16)
t(v,11q)
+12
+19
+8
-7
−Y
del(3q)
del(5q)
del(6q)
del(7q)
del(9p)
del(9q)
del(11q)
del(12p)
del(13q)
del(17p)
del(20q)
I(17q)
inv(3)
Inv(3q)
inv(16)
Monosomy 13
Monosomy 14
Monosomy 16
Monosomy 17
OTHER
Detail (Cytogenetics)
PNH Clone
Detected
Not detected
Not done
BM Blast (%)
*
< 5%
5 - 10%
11 - 20%
21 - 30%
> 30%
Unknown
Pending
IPSS Score
*
Low (0)
Intermediate-1 (0.5-1.0)
Intermediate-2 (1.5-2)
High (>2.5)
Unknown
Transformed into AML
Yes
No
Transformed date
-
Day
-
Month
Year
Date
Memo
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MPN
WHO - Myeloid
*
JAK2
*
Wildtype
Detected
Homozygous
Heterozygous
Unknown
CALR
*
Wildtype
Detected
Homozygous
Heterozygous
Unknown
MPL
*
Wildtype
Detected
Homozygous
Heterozygous
Unknown
Hb
Platelet
WBC
Hepatomegaly
Yes
No
Unknown
Splenomegaly
Yes
No
Unknown
BM Blast (%)
*
< 5%
5 - 10%
11 - 20%
21 - 30%
> 30%
Unknown
Pending
Cytogenetics
Normal karyotype
Complex karyotype
NOT DONE
NOT AVAILABLE
SHORT SPREAD
Hyperdiploidy
Hypodiploidy
t(1;19)
t(3;3)
t(3q)
t(4;11)
t(4;14)
t(5;17)
t(6;9)
t(6;11)
t(6;14)
t(8;14)
t(8;21)
t(9;11)
t(9;22)
t(10;11)
t(11;14)
t(11;17)
t(11;19)
t(12;21)
t(14;16)
t(14;20)
t(15;17)
t(16;16)
t(v,11q)
+12
+19
+8
-7
−Y
del(3q)
del(5q)
del(6q)
del(7q)
del(9p)
del(9q)
del(11q)
del(12p)
del(13q)
del(17p)
del(20q)
I(17q)
inv(3)
Inv(3q)
inv(16)
Monosomy 13
Monosomy 14
Monosomy 16
Monosomy 17
OTHER
Detail (Cytogenetics)
DIPSS Risk score for Myelofibrosis
*
Low risk
Intermediate-1
Intermediate-2
High risk
Not evaluated
Transformed
*
Yes
No
Transformed date
-
Day
-
Month
Year
Date
Transformed to
myelofibrosis from PV/ET
AML
Memo
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MDS/MPN
WHO - Myeloid
*
Hb
Platelet
WBC
Hepatomegaly
Yes
No
Unknown
Splenomegaly
Yes
No
Unknown
BM Blast (%)
< 5%
5 - 10%
11 - 20%
21 - 30%
> 30%
Unknown
Pending
Cytogenetics
Normal karyotype
Complex karyotype
NOT DONE
NOT AVAILABLE
SHORT SPREAD
Hyperdiploidy
Hypodiploidy
t(1;19)
t(3;3)
t(3q)
t(4;11)
t(4;14)
t(5;17)
t(6;9)
t(6;11)
t(6;14)
t(8;14)
t(8;21)
t(9;11)
t(9;22)
t(10;11)
t(11;14)
t(11;17)
t(11;19)
t(12;21)
t(14;16)
t(14;20)
t(15;17)
t(16;16)
t(v,11q)
+12
+19
+8
-7
−Y
del(3q)
del(5q)
del(6q)
del(7q)
del(9p)
del(9q)
del(11q)
del(12p)
del(13q)
del(17p)
del(20q)
I(17q)
inv(3)
Inv(3q)
inv(16)
Monosomy 13
Monosomy 14
Monosomy 16
Monosomy 17
OTHER
Detail (Cytogenetics)
Transformed into AML
Yes
No
Transformed date
-
Day
-
Month
Year
Date
Memo
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Bone Marrow Failure
Sub-classification
*
Other
Hb
*
Platelet
*
WBC
*
Cytogenetics
Normal karyotype
Complex karyotype
NOT DONE
NOT AVAILABLE
SHORT SPREAD
Hyperdiploidy
Hypodiploidy
t(1;19)
t(3;3)
t(3q)
t(4;11)
t(4;14)
t(5;17)
t(6;9)
t(6;11)
t(6;14)
t(8;14)
t(8;21)
t(9;11)
t(9;22)
t(10;11)
t(11;14)
t(11;17)
t(11;19)
t(12;21)
t(14;16)
t(14;20)
t(15;17)
t(16;16)
t(v,11q)
+12
+19
+8
-7
−Y
del(3q)
del(5q)
del(6q)
del(7q)
del(9p)
del(9q)
del(11q)
del(12p)
del(13q)
del(17p)
del(20q)
I(17q)
inv(3)
Inv(3q)
inv(16)
Monosomy 13
Monosomy 14
Monosomy 16
Monosomy 17
OTHER
Detail (Cytogenetics)
PNH Clone
Detected
Not detected
Not done
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Inherited Disorders
Memo
*
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Histiocytic Disorders
Classification
*
Memo
*
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Autoimmune Disease
Memo
*
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Haemoglobinopathy
Diagnosis
*
Thalassaemia
Sickle cell disease
Other
Other
Thalassaemia type
*
Beta major
Beta intermedia
Beta trait
E-beta
HbH
Alpha trait
Constant Spring
Hb Adana
HbH-CS
Hb E
Memo
*
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Other diagnosis
Memo
*
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Results and Treatment
Diagnostic BMA and Trephine / Biopsy HPE Result
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Select Diagnostic BMA / HPE Report
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Diagnostic Immunophenotyping
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Select Diagnostic IP Report
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CT/PET Scan (If relevant)
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Select Diagnostic Scan Report
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History, Presentation, Treatment Received and Response
*
Treatment Plan and Roadmap
*
Chemoport/PICC
*
Yes
No
Date inserted
-
Day
-
Month
Year
Date
History of bactaraemia or infected chemoport/PICC since insertion?
*
Yes
No
If Yes, please elaborate
Any significant problems occurred before - fungal infection, severe bacteraemia, ICU/HDW stay,ventilation etc
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Transplant
Type of Transplant
*
Autologous
Allogenic - fully matched sibling
Allogenic - mis-matched sibling
Allogenic - matched unrelated
Cord Blood Transplant - full matched
Cord Blood Transplant - mismatched
Haploidentical
Preferred Counselling Date
PBSC Collected?
*
Yes
No
PBSC Collection Date
*
-
Day
-
Month
Year
Date
PBSC dose (x10^6/kg)
*
Preferred Transplant Date
*
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Donor's Detail
Name of donor
*
IC
*
xxxxxx-xx-xxxx
Age
*
Sex
*
Male
Female
Race
*
Bumiputera Sabah
Bumiputera Sarawak
Chinese
Foreigner
Indian
Malay
Other
Orang Asli Semenanjung
Sikh
Siamese Malaysia
HLA Result
Browse Files / Pictures
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Important issue:( i.e.high risk behaviour, Hepatitis B/C, age / co-morbidities)
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Referred by
*
Referring hospital
*
Designation
*
Email address
*
Please include all the relevant person's email addresses from your ward/centre
Tel no.
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