REGISTRATION FORM 1 / 2

Transcription

1 IDENTIFICATION AND BASELINE DATA REGISTRATION FORM 1 / 2 M Patient s initials: Sequential case N : SEX : F Date of birth: Place of birth I I Centre I I Address I I Telephone number I I Actual profession I I Previous professions I I Previous exposure to toxic substance: if yes specify I I Smoking Y N if yes how long I I cigarette/die I I Anamnesis of hypersensitivity or autoimmune disease Y N if yes specify Anamnesis of previous acute or chronic pulmonary disease if yes specify Previous tumour Y N if yes specify DIAGNOSIS Patient age at diagnosis Performance status (PS): IPI: B symptoms: if yes specify : Night sweats Unexplained fevers Unexplained weight loss ( 10% in the last 6 months) Other symptoms If yes specify other I I Date of biopsy: Diagnosis: I I Biopsy's site: Histological number STAGE AT DIAGNOSIS : Ann Arbor modified by Ferraro BONE MARROW Date of assessment: IE II1E II2E II2EW IIIE IVE Mean % infiltration by tumour cells: Biopsy: % Aspirate: %

2 DIAGNOSIS MODALITY Thorax Rx TAC total body PET Trans-thoracic biopsy Major surgery Broncoscopy BIOLOGICAL PARAMETERS REGISTRATION FORM 2 / 2 if yes specify Date : Hb (g/dl) WBC count (10 9 /l) Neutrophils (%) Lymphocytes (%) Monocytes (%) Eosinophils (%) Basophils (%) PLT (10 9 /l) Specific tests-serology BETA-2 (mg/l) VES (mm/hr) Creatinine (mg/dl) Calcium (mg/dl) GPT/ALT (U/L) Alkaline phosphatase (U/L) Protein (g/dl) Albumin (%) LDH (U/L) Positive Negative Not done HIV HCV IMMUNOPHENOTYPE OF DIAGNOSTIC BIOPSY CD3 POS NEG CD5 POS NEG CD10 POS NEG CD20 POS NEG CD 23 POS NEG CD 43 POS NEG CD 79a POS NEG Kappa POS NEG Lambda POS NEG Ki 67 Bcl10 POS NEG RESEARCH for IgH gene alteration with PCR Fluorescence In Situ Hybridization analysis to research t(14;18)(q32;q21) Fluorescence In Situ Hybridization analysis to research t(11;18)(q21;q21) Fluorescence In Situ Hybridization analysis to research t(1;14)(p22;q32)

3 FIRST LINE THERAPY DATE OF START OF FIRST THERAPY: DATE OF END OF FIRST THERAPY: FIRST THERAPY: CHEMOTHERAPY ANTIBIOTICS SURGERY RADIOTHERAPY OTHER DATE OF RESPONSE: Serology after first line treatment:

4 SECOND LINE THERAPY IF PD AFTER FIRST LINE THERAPY DATE: SITE OF RELAPSE: NODAL SPECIFY : EXTRANODAL SPECIFY. DATE OF START OF SECOND THERAPY: DATE OF END OF SECOND THERAPY: SECOND THERAPY: CHEMOTHERAPY ANTIBIOTICS OTHER RADIOTHERAPY SURGERY DATE OF RESPONSE: Serology after second line treatment:

5 THIRD LINE THERAPY IF PD AFTER SECOND LINE THERAPY DATE: SITE OF RELAPSE: NODAL SPECIFY : EXTRANODAL SPECIFY. DATE OF START OF THIRD THERAPY: DATE OF END OF THIRD THERAPY: THIRD THERAPY: CHEMOTHERAPY ANTIBIOTICS OTHER RADIOTHERAPY SURGERY DATE OF RESPONSE: Serology after third line treatment:

6 FOURTH LINE THERAPY IF PD AFTER THIRD LINE THERAPY DATE: SITE OF RELAPSE: NODAL SPECIFY : EXTRANODAL SPECIFY. DATE OF START OF FOURTH THERAPY: DATE OF END OF FOURTH THERAPY: FOURTH THERAPY: CHEMOTHERAPY ANTIBIOTICS OTHER RADIOTHERAPY SURGERY DATE OF RESPONSE: Serology after fourth line treatment:

7 FOLLOW UP FORM Date of last follow-up: Surname : Name: : c/c : SEX : M F Date of birth: Centre: I I CURRENT STATUS ALIVE Status DEATH Date of death: Cause of death: Second tumour: If yes specify type of 2 nd tumour:. Date of second tumour diagnosis: