untitled h1
22 appendix g blgsp enrollment

Instructions: *The Clinical Data needed to complete this Enrollment Form should be collected for each patient in the* Burkitt Lymphoma Genome Sequencing Project (BLGSP) prior *to acquisition of tissues. Upon qualification notice* from the Office of Cancer Genomics (OCG), the Tissue Source Site (TSS) should complete this Enrollment form for each qualified case within 60 days.  
Questions regarding this form should be directed to the Nationwide Children's Hospital (NCH) or OCG.  
Please note the following definitions for the "Unknown" and "Not Evaluated" answer options on this form.  
Unknown: This answer option should only be selected if the TSS does not know this information after all efforts to obtain the data have been exhausted. If this answer option is selected for a question that is part of the BLGSP required data set, the TSS must complete a discrepancy note providing a reason why the answer is unknown.  
Not Evaluated: This answer option should only be selected by the TSS if it is known that the information being requested cannot be obtained. This could be because the test in question was never performed on the patient or the TSS knows that the information requested was never disclosed.  
Tissue Source Site (TSS): ____________________________TSS Identifier: _____________ TSS Unique Patient Identifier: _______________________________
Completed By *(Interviewer Name in OpenClinica)*: __________________________________________Completed Date: ___________________________________  
| #                                                                                                                                                                      | Data Element                                                                                                                                                                                                                              | Entry Alternatives                                                                                                                                                                                                                               | Working Instructions                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  |                 |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------|
| General Information BLGSP Project ID:                                                                                                                                  | Indicate whether the TSS providing tissue is  contracted for prospective tissue collection. If  the submitted tissue was collected after the date  the BLGSP contract was executed, the tissue  has been collected prospectively. 3088492 |                                                                                                                                                                                                                                                  |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |                 |
| *1                                                                                                                                                                     | Is this a prospective                                                                                                                                                                                                                     |  Yes                                                                                                                                                                                                                                            |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |                 |
| tissue collection?                                                                                                                                                     |  No                                                                                                                                                                                                                                      | Indicate whether the TSS providing tissue is  contracted for retrospective tissue collection. If  the submitted tissue was collected prior to the  date the BLGSP contract was executed, the  tissue has been collected retrospectively. 3088528 |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |                 |
| Patient Information Demographic Information Is this a  *2 retrospective tissue  collection?                                                                            |  Yes  No                                                                                                                                                                                                                                | Provide the date the patient was born. 2896950 (month), 2896952 (day), 2896954 (year)                                                                                                                                                            |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |                 |
| *3                                                                                                                                                                     | Date of Birth                                                                                                                                                                                                                             | _____ _____ /                                                                                                                                                                                                                                    | _____ _____ /                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         | ___ ___ ___ ___ |
| (month)                                                                                                                                                                | (day)                                                                                                                                                                                                                                     | (year)                                                                                                                                                                                                                                           | Note: The day of Birth is not required. Provide the patient's gender using the provided  categories.  2200604                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         |                 |
| *4                                                                                                                                                                     | Gender                                                                                                                                                                                                                                    |  Female  Male                                                                                                                                                                                                                                  | Provide the patient's race using the defined  categories. 3009519 American Indian or Alaska Native: A person  having origins in any of the original peoples of  North and South America (including Central  America), and who maintains tribal affiliation  or community attachment. Asian: A person having origins in any of the  original peoples of the far East, Southeast Asia,  or in the Indian subcontinent including, for  example, Cambodia, China, India, Japan, Korea,  Malaysia, Pakistan, the Philippine Islands,  Thailand, and Vietnam. White: A person having origins in any of the  original peoples of the four Europe, the Middle  East, or North Africa. Black or African American: A person having  origins in any of any of the black racial groups  of Africa. Terms such as "Haitian" or "Negro"  can be used in addition to "Black or African  American." Native Hawaiian or other Pacific Islander: A  person having origins in any of the original  peoples of Hawaii, Guam, Samoa, or other  Pacific Islands. Unknown: Could not be determined or unsure |                 |
| *6                                                                                                                                                                     | Other Race                                                                                                                                                                                                                                | ____________________________                                                                                                                                                                                                                     | If the patient's race was not defined in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          |                 |
|  American Indian or Alaska Native  Asian/East Indian  White  Black/African American  Native Hawaiian or other Pacific Islander  Other (please specify)  Unknown |                                                                                                                                                                                                                                           |                                                                                                                                                                                                                                                  |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |                 |
| Race                                                                                                                                                                   |                                                                                                                                                                                                                                           |                                                                                                                                                                                                                                                  |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |                 |
| *5                                                                                                                                                                     | (check all that  apply)                                                                                                                                                                                                                   |                                                                                                                                                                                                                                                  |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |                 |  
| #                                                                      | Data Element                                                                                                                                                                                                                                                                                                                                                                                                                                              | Entry Alternatives                                                                                                         | Working Instructions                                                                                                                                                                                                                                            |                                                                                                                                                   |
|------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------|
| Only complete if  "other" is selected in  #5.                          | previous question, provide the patient's race. 2192205 Provide the patient's ethnicity using the defined  categories.  2192217 Not Hispanic or Latino: A person not meeting  the definition of Hispanic or Latino. Hispanic or Latino: A person of Mexican,  Puerto Rican, Cuban, Central or South  American, or other Spanish culture or origin,  regardless of race. Not Reported: Not provided or available Unknown: Could not be determined or unsure |                                                                                                                            |                                                                                                                                                                                                                                                                 |                                                                                                                                                   |
|  Not Hispanic or Latino  Hispanic or Latino  Not Reported  Unknown |                                                                                                                                                                                                                                                                                                                                                                                                                                                           |                                                                                                                            |                                                                                                                                                                                                                                                                 |                                                                                                                                                   |
| 7                                                                      | Ethnicity                                                                                                                                                                                                                                                                                                                                                                                                                                                 | Provide the patient's height (centimeters) at the  time the patient was diagnosed with the tumor  submitted for BLGSP. 649 |                                                                                                                                                                                                                                                                 |                                                                                                                                                   |
| Height                                                                 |                                                                                                                                                                                                                                                                                                                                                                                                                                                           |                                                                                                                            |                                                                                                                                                                                                                                                                 |                                                                                                                                                   |
| 8                                                                      | (at time of                                                                                                                                                                                                                                                                                                                                                                                                                                               | _____________________________(cm)                                                                                          |                                                                                                                                                                                                                                                                 |                                                                                                                                                   |
| diagnosis)                                                             | Provide the patient's weight (kilograms) at the  time the patient was diagnosed with the tumor  submitted for BLGSP. 651                                                                                                                                                                                                                                                                                                                                  |                                                                                                                            |                                                                                                                                                                                                                                                                 |                                                                                                                                                   |
| Weight                                                                 |                                                                                                                                                                                                                                                                                                                                                                                                                                                           |                                                                                                                            |                                                                                                                                                                                                                                                                 |                                                                                                                                                   |
| 9                                                                      | (at time of                                                                                                                                                                                                                                                                                                                                                                                                                                               | _____________________________(kg)                                                                                          |                                                                                                                                                                                                                                                                 |                                                                                                                                                   |
| diagnosis)                                                             |                                                                                                                                                                                                                                                                                                                                                                                                                                                           |                                                                                                                            |                                                                                                                                                                                                                                                                 |                                                                                                                                                   |
| Survival Information Vital Status *10 (at date of last  contact)       | The survival state of the person registered on  the protocol. 5                                                                                                                                                                                                                                                                                                                                                                                           |                                                                                                                            |                                                                                                                                                                                                                                                                 |                                                                                                                                                   |
|  Alive  Dead                                                         | If the patient is living, provide the date of last  contact with the patient (as reported by the  patient, medical provider, family member, or  caregiver).  2897020 (month), 2897022 (day),  2897024 (year) Note: The day of Last Contact is not required.                                                                                                                                                                                               |                                                                                                                            |                                                                                                                                                                                                                                                                 |                                                                                                                                                   |
| *11                                                                    | Date of Last Contact                                                                                                                                                                                                                                                                                                                                                                                                                                      | ____ _____ /                                                                                                               | _____ _____ /                                                                                                                                                                                                                                                   | ___ ___ ___ ___                                                                                                                                   |
| (month)                                                                | (day)                                                                                                                                                                                                                                                                                                                                                                                                                                                     | (year)                                                                                                                     | Indicate the last date the patient was known to  be alive, regardless of whether the patient,  medical provider, family member or caregiver  was contacted. 2975722 (month), 2975724 (day),  2975726 (year) Note: The day of Last Known Alive is not  required. |                                                                                                                                                   |
| *12                                                                    | Date of Last Known                                                                                                                                                                                                                                                                                                                                                                                                                                        | ____ _____ /                                                                                                               | ____ ____ /                                                                                                                                                                                                                                                     | __ ___ ___ ___                                                                                                                                    |
| Alive                                                                  | (month)                                                                                                                                                                                                                                                                                                                                                                                                                                                   | (day)                                                                                                                      | (year)                                                                                                                                                                                                                                                          | If the patient is deceased, provide the month of  death.  2897026, (month) 2897028 (day),  2897030 (year) Note: The day of Death is not required. |
| *13                                                                    | Date of Death                                                                                                                                                                                                                                                                                                                                                                                                                                             | ____ ____ /                                                                                                                | ____ ____ /                                                                                                                                                                                                                                                     | ___ ___ ___ ___                                                                                                                                   |
| (month)                                                                | (day)                                                                                                                                                                                                                                                                                                                                                                                                                                                     | (year)                                                                                                                     |                                                                                                                                                                                                                                                                 |                                                                                                                                                   |
| Cause of Death                                                         |                                                                                                                                                                                                                                                                                                                                                                                                                                                           |                                                                                                                            |                                                                                                                                                                                                                                                                 |                                                                                                                                                   |
| 6                                                                      | Only complete if  patient is deceased.                                                                                                                                                                                                                                                                                                                                                                                                                    |  Cancer Related                                                                                                           |  Non-Cancer Related                                                                                                                                                                                                                                            | Indicate the patient's cause of death.                                                                                                            |
|  Unknown                                                              |  Other (please specify)                                                                                                                                                                                                                                                                                                                                                                                                                                  | 2554674                                                                                                                    |                                                                                                                                                                                                                                                                 |                                                                                                                                                   |
| 7                                                                      | Other Cause of                                                                                                                                                                                                                                                                                                                                                                                                                                            | ____________________________________                                                                                       | If the patient's cause of death was not included                                                                                                                                                                                                                |                                                                                                                                                   |  
| Death Only complete if  "other" is selected in  #6.                                 | in the provided list, specify the patient's cause  of death. 2004150                                                                                                                                                                  |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     |
|-------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Patient Status (Regarding Submitted Tumor)                                          | Indicate whether the patient received treatment  (radiation, pharmaceutical, or both) prior to the  procurement of the sample submitted for  BLGSP. 3382737 If the answer to this question is "yes", the  submitted case is excluded. |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     |
| Did the patient  receive neo-adjuvant  therapy for the  tumor submitted for  BLGSP? |  Yes (exclusion criterion)  No                                                                                                                                                                                                      |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     |
| *14                                                                                 | Indicate whether the patient was tumor/disease  free (i.e. free of the malignancy that yielded the  sample submitted for the BLGSP study) at the  date of last contact or death.  2759550                                             |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     |
| Tumor Status                                                                        |                                                                                                                                                                                                                                       |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     |
| *15                                                                                 | (at time of last  contact or death)                                                                                                                                                                                                   |  Tumor free  With tumor  Unknown   0: Fully active, able to carry on all pre-disease  performance without restriction.   1: Restricted in physically strenuous activity  but ambulatory and able to carry out work of a  light or sedentary nature, e.g., light  housework, office work.  2: Ambulatory and capable of all selfcare but  unable to carry out any work activities. Up  and about more than 50% of waking hours.  3: Capable of only limited selfcare, confined  to bed or chair more than 50% of waking  hours.   4: Completely disabled. Cannot carry on any  selfcare. Totally confined to bed or chair.  Unknown  Not Evaluated Provide the Eastern Cooperative Oncology  Group (ECOG) performance status of the  patient at the time selected in the "timing"  question below. 88                      |
| Performance Status:                                                                 |                                                                                                                                                                                                                                       |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     |
| 16                                                                                  | Eastern Cooperative  Oncology Group                                                                                                                                                                                                   |  100: Normal, no complaints, no evidence of  disease  90: Able to carry on normal activity; minor  signs or symptoms of disease  80: Normal activity with effort; some signs or  symptoms of disease  70: Cares for self, unable to carry on normal  activity or to do active work  60: Requires occasional assistance, but is able  to care for most of his/her needs.  50: Requires considerable assistance and  frequent medical care  40: Disabled, requires special care and  assistance  30: Severely disabled, hospitalization  indicated. Death not imminent.   20: Very sick, hospitalization indicated. Death  not imminent.  10: Moribund, fatal processes progressing  rapidly  0: Dead  Unknown Provide the Karnofsky score for the patient at  the time selected in the "timing" question  below. 2003853 |
| 17                                                                                  | Performance Status:  Karnofsky Score                                                                                                                                                                                                  |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     |  
|  Not Evaluated  Preoperative  Pre-adjuvant Therapy  Adjuvant Therapy  Post-adjuvant Therapy  Unknown                                                                                          | Indicate the timing of the performance  status(es) provided in the previous question(s). 2792763                                                                                                |                                                                                                                                                                          |                                                                                                  |
|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------|
| 18                                                                                                                                                                                                  | Performance Status  Score: Timing                                                                                                                                                               | Indicate the patient's measure of success after  their primary treatment for the tumor submitted  for HTMCP. Treatment includes surgery and  adjuvant therapies. 2786727 |                                                                                                  |
| Treatment                                                                                                                                                                                           |  Progressive Disease  Stable Disease  Partial Response  Complete Response                                                                                                                   |                                                                                                                                                                          |                                                                                                  |
| 18                                                                                                                                                                                                  | Tumor Response                                                                                                                                                                                  |  Initial  Adjuvant  Progression after initial  Recurrence  Palliative  Unknown                                                                                     | Text term to identify the reason for the  administration of a treatment regimen.  2793511        |
| *19                                                                                                                                                                                                 | Indication of  Regimen                                                                                                                                                                          |  Chemotherapy  Radiation  Radiation and Chemotherapy  Stem Cell Transplant  Surgery  No Treatment  Other Treatment                                                | Text term that describes the kind of treatment  that was given for the primary lymphoma. 3284925 |
| *20                                                                                                                                                                                                 | Lymphoma  Treatment Type                                                                                                                                                                        | Indicate the other treatment type for the                                                                                                                                |                                                                                                  |
| *21                                                                                                                                                                                                 | If other, specify                                                                                                                                                                               | ____________________________________                                                                                                                                     | lymphoma. 2861111                                                                                |
| Chemotherapy                                                                                                                                                                                        | Date chemotherapy started.                                                                                                                                                                      |                                                                                                                                                                          |                                                                                                  |
| 22                                                                                                                                                                                                  | Chemotherapy  Start Date                                                                                                                                                                        | __ __ / __ __ / __ __ __ __                                                                                                                                              | 2897050 (month), 2897052 (day), 2897054  (year)                                                  |
| Did  chemotherapy  end during this  reporting  period?                                                                                                                                              |  Yes                                                                                                                                                                                           | Indicate whether chemotherapy administration                                                                                                                             |                                                                                                  |
|  No                                                                                                                                                                                                | ended during this reporting period. 2188260                                                                                                                                                     |                                                                                                                                                                          |                                                                                                  |
| 23                                                                                                                                                                                                  | Date chemotherapy ended.                                                                                                                                                                        |                                                                                                                                                                          |                                                                                                  |
| 24                                                                                                                                                                                                  | Chemotherapy  End Date                                                                                                                                                                          | __ __ / __ __ / __ __ __ __                                                                                                                                              | 2897056 (month), 2897058 (day), 2897060  (year)                                                  |
|  BACOP  C-MOPP  CAP-BOP  CHOP + Bleomycin  CHOP + Etoposide  CHOP-14  CHOP-14 + Rituximab  CHOP-21  CHOP-21 + Rituximab  CNOP  CODOX + Rituximab  CVP  DA-EPOCH  DA-EPOCH + Rituxumab | Text term or code to represent the name of a  pharmaceutical regimen containing two or more  agents which are given together or separately to  treat a patient with malignant lymphoma. 3366758 |                                                                                                                                                                          |                                                                                                  |
| *25                                                                                                                                                                                                 | Pharmaceutical  Regimen                                                                                                                                                                         |                                                                                                                                                                          |                                                                                                  |  
|  F-MACHOP  High Dose Methotrexate w/Leucovorin  HyperCVAD-Mtx/AraC + Rituximab  ICE  ICE + Rituxumab  LNH-84  LNH-87  M-BACOP  MACOP-B  ProMace-CytaBOM  ProMace-MOPP  VACOP-B  Vanderbilt regimen + Rituximab  Single Agent Therapy (please specify)  Other Pharmaceutical Regimen (please  specify)  Unknown   |
|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|  
| Text term or abbreviation to represent another  name of a pharmaceutical regimen containing  two or more agents which are given together or  separately to treat a patient with malignant  lymphoma that was not already mentioned or  specified. 3366930                                                                                                                                 |                                                                                                                                                                                                                                                                                                                                                                                                                              |                                                                                                                                                                                                                                |                                                |
|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------|
| If Other  Pharmaceutical  Regimen,  specify                                                                                                                                                                                                                                                                                                                                               |                                                                                                                                                                                                                                                                                                                                                                                                                              |                                                                                                                                                                                                                                |                                                |
| 26                                                                                                                                                                                                                                                                                                                                                                                        | If Single-Agent                                                                                                                                                                                                                                                                                                                                                                                                              |                                                                                                                                                                                                                                |                                                |
| 27                                                                                                                                                                                                                                                                                                                                                                                        | Therapy,  specify                                                                                                                                                                                                                                                                                                                                                                                                            | Text name for agent used without other agents  in a treatment regimen or study. 3590022 The total number of cycles administered to the  patient of a protocol specified drug or therapy  agent as of the current report. 62590 |                                                |
| Radiation Therapy  28 Number of  Cycles Radiation                                                                                                                                                                                                                                                                                                                                         | Date radiation therapy started.                                                                                                                                                                                                                                                                                                                                                                                              |                                                                                                                                                                                                                                |                                                |
| 29                                                                                                                                                                                                                                                                                                                                                                                        | Therapy Start                                                                                                                                                                                                                                                                                                                                                                                                                | __ __ / __ __ / __ __ __ __                                                                                                                                                                                                    | 2897100 (month), 2897102 (day), 2897104        |
| Date                                                                                                                                                                                                                                                                                                                                                                                      | (year)                                                                                                                                                                                                                                                                                                                                                                                                                       |                                                                                                                                                                                                                                |                                                |
| Did radiation  therapy end  during this  reporting  period?                                                                                                                                                                                                                                                                                                                               |  Yes                                                                                                                                                                                                                                                                                                                                                                                                                        | Indicate whether radiation therapy ended during                                                                                                                                                                                |                                                |
|  No                                                                                                                                                                                                                                                                                                                                                                                      | this reporting period.                                                                                                                                                                                                                                                                                                                                                                                                       |                                                                                                                                                                                                                                |                                                |
| 30                                                                                                                                                                                                                                                                                                                                                                                        | Radiation                                                                                                                                                                                                                                                                                                                                                                                                                    | Date radiation therapy ended.                                                                                                                                                                                                  |                                                |
| 31                                                                                                                                                                                                                                                                                                                                                                                        | Therapy End                                                                                                                                                                                                                                                                                                                                                                                                                  | __ __ / __ __ / __ __ __ __                                                                                                                                                                                                    | 2897106 (month), 2897108 (day), 2897110        |
| Date                                                                                                                                                                                                                                                                                                                                                                                      | (year)                                                                                                                                                                                                                                                                                                                                                                                                                       |                                                                                                                                                                                                                                |                                                |
| Total Dose of                                                                                                                                                                                                                                                                                                                                                                             | A numeric value for the total dose volume of                                                                                                                                                                                                                                                                                                                                                                                 |                                                                                                                                                                                                                                |                                                |
| 32                                                                                                                                                                                                                                                                                                                                                                                        | Radiation                                                                                                                                                                                                                                                                                                                                                                                                                    | __________________________ (Gy)                                                                                                                                                                                                | radiation therapy given to a patient, in Gray. |
| Therapy                                                                                                                                                                                                                                                                                                                                                                                   | 36                                                                                                                                                                                                                                                                                                                                                                                                                           |                                                                                                                                                                                                                                |                                                |
|  Abdomen, total  Arm  Body, total  Bone, non-spine  Brain, focal  Brain, whole  Breast  Chest wall  Eye  Gastrointestinal, colon  Gastrointestinal, gallbladder  Gastrointestinal, intestine  Gastrointestinal, Liver  Gastrointestinal, NOS  Gastrointestinal, Pancreas  Gastrointestinal, Stomach  Genitourinary, Bladder  Genitourinary, Kidney  Genitourinary, NOS |  Head, Face,  or Neck  Leg  Lung  Lymph node,  distant (specify  site)  Lymph node,  locoregional  (specify site)  Lymph  Nodes  Mantle  Mediastinum  Parametrium  Pelvis  Shoulder  Skin, lower  extremity, local  Skin, total  Skin, trunk,  local  Skin, upper  extremity, local  Spine  Text term to identify anatomically-specified  areas or fields that are targeted for radiation  therapy. 2416537 |                                                                                                                                                                                                                                |                                                |
| Radiation                                                                                                                                                                                                                                                                                                                                                                                 |                                                                                                                                                                                                                                                                                                                                                                                                                              |                                                                                                                                                                                                                                |                                                |
| 33                                                                                                                                                                                                                                                                                                                                                                                        | Field,  extranodal                                                                                                                                                                                                                                                                                                                                                                                                           |                                                                                                                                                                                                                                |                                                |  
| Supraclavicular  Thorax  Trunk  Other  Unknown                                                                                                                                                                                                         |                                                                               |                                                                                                 |                                        |     |                                             |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------|----------------------------------------|-----|---------------------------------------------|
|  Axillary   Cervical   Epitrochlear   Femoral   Hilar   Iliac-common   Iliac-external   Inguinal   Mediastinal   Mesenteric   Occipital   Paraaortic   Parotid   Popliteal   Retroperitoneal   Splenic   Submandibular   Supraclavicular | Identify lymph node sites targeted for radiation  therapy. 3762198            |                                                                                                 |                                        |     |                                             |
| 34                                                                                                                                                                                                                                                         | Nodal Regions  Targeted                                                       |                                                                                                 |                                        |     |                                             |
| 35                                                                                                                                                                                                                                                         | Other, specify                                                                | _________________________                                                                       | Specify other field of radiation 62999 |     |                                             |
| Stem Cell Transplantation  Type of Stem  36 Cell  Transplantation  Autologous  Syngeneic/Allogeneic related donor  Allogeneic, unrelated donor                                                                                                          | Indicate the hematopoietic stem cell source  type. 2957417                    |                                                                                                 |                                        |     |                                             |
| Date of Stem                                                                                                                                                                                                                                               | Indicate the date of the hematopoietic stem                                   |                                                                                                 |                                        |     |                                             |
| 37                                                                                                                                                                                                                                                         | Cell                                                                          | __ __ / __ __ / __ __ __ __                                                                     | cell transplant.                       |     |                                             |
| Transplantation                                                                                                                                                                                                                                            | 3718671                                                                       |                                                                                                 |                                        |     |                                             |
| Surgery                                                                                                                                                                                                                                                    | Indicate the date related to the procedure of                                 |                                                                                                 |                                        |     |                                             |
| __ __ / __ __ / __ __ __ __                                                                                                                                                                                                                                | surgically removing as much of the tumor as  possible being executed. 2839523 |                                                                                                 |                                        |     |                                             |
| Date of cancer                                                                                                                                                                                                                                             |                                                                               |                                                                                                 |                                        |     |                                             |
| 38                                                                                                                                                                                                                                                         | debulking  surgery                                                            |  Progressive Disease                                                                           |  Complete                             |     |                                             |
|  Persistent Disease                                                                                                                                                                                                                                       | Remission/Resp                                                                |                                                                                                 |                                        |     |                                             |
|  Stable Disease                                                                                                                                                                                                                                           | onse                                                                          |                                                                                                 |                                        |     |                                             |
|  Partial Remission/ Response                                                                                                                                                                                                                              |  Unknown  Not  Applicable  (treatment  ongoing)                             | Indicate the patient's measure of success after  the initial first course of treatment. 2786727 |                                        |     |                                             |
| Measure of  Success of  Outcome at the  Completion of  Initial First  Course  Treatment                                                                                                                                                                    |                                                                               |                                                                                                 |                                        |     |                                             |
| 39                                                                                                                                                                                                                                                         |                                                                               |                                                                                                 |                                        |     |                                             |
| Patient History of Disease HIV Status  Positive *40 HIV antibody status  Negative  Unknown                                                                                                                                                              | Indicate whether the patient is HIV positive. 2180464                         |                                                                                                 |                                        |     |                                             |
| 41                                                                                                                                                                                                                                                         | Date of HIV                                                                   | _____ _____                                                                                     | _____ _____ /                          | ___ | Provide the month the patient was diagnosed |  
| Diagnosis (if                                          | /                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      | (day)                                                                                                                                                         | __                                                                                                        |          |              |     |                |
|--------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------|----------|--------------|-----|----------------|
| known)                                                 | (month)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                | ___ __  ___ __  ___ __ (y ea r)                                                                                                                               | with HIV. 3579640 (month), 3579644 (day),  3579643 (year) Note: The day of HIV Diagnosis is not required. |          |              |     |                |
| Nadir CD4 Counts                                       | Provide the patient's Nadir CD4 counts, which                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          |                                                                                                                                                               |                                                                                                           |          |              |     |                |
| 42                                                     | (at time of last                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       | ____________________________ (cells/mm3 )                                                                                                                     | are the lowest CD4 counts the patient has had.                                                            |          |              |     |                |
| contact)                                               | 2684395                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                |                                                                                                                                                               |                                                                                                           |          |              |     |                |
| CD4 Counts at  Diagnosis of the  Submitted  Malignancy | Provide the patient's CD4 Counts at the time  the patient was diagnosed with the malignancy  submitted for the BLGSP study. 2922654                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    |                                                                                                                                                               |                                                                                                           |          |              |     |                |
| 43                                                     | ____________________________ (cells/mm3 )                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              | Provide the HIV RNA load (also known as the  "viral load") at the time the patient was  diagnosed with the malignancy submitted for  the BLGSP study. 2922674 |                                                                                                           |          |              |     |                |
| HIV RNA load at  Diagnosis of  Submitted  Malignancy   |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |                                                                                                                                                               |                                                                                                           |          |              |     |                |
| 44                                                     | ____________________________ (counts/mL)  Candidiasis of bronchi, trachea or lungs  Candidiasis, esophageal  CMV other than liver, spleen or nodes, onset  at age >1month  CMV retinitis  Coccidioidomycosis, disseminated or  extrapulmonary  Cryptococcosis, extrapulmonary  Cryptosporidiosis, chronic intestinal  Encephalopathy, HIV-related  Herpes simplex: chronic ulcers (> 1 month's  duration) or bronchitis, pneumonitis or  esophagitis (onset at age > 1 month)  Histoplasmosis, disseminated or  extrapulmonary  Isosporiasis, chronic intestinal (> 1 mon)  Mycobacterium avium complex or  Mycobacterium kansasii disseminated or  extrapulmonary  Mycobacterium tuberculosis of any site,  pulmonary, disseminated or extrapulmonary  Mycobacterium, other species or unidentified  species, disseminated or extrapulmonary  Nocardiosis  Pneumocystis jirovecii pneumonia  Pneumonia, recurrent  Progressive multifocal leukoencephalopathy  Salmonella septicemia, recurrent  Toxoplasmosis of the brain, onset at age  >1month  Wasting syndrome, due to HIV | Prior to the malignancy submitted for the  BLGSP study, provide any AIDS defining  conditions. 2679581                                                        |                                                                                                           |          |              |     |                |
| 45                                                     | Prior AIDS  Defining Conditions                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |                                                                                                                                                               |                                                                                                           |          |              |     |                |
| v46                                                    | Co-Infections                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          | Test                                                                                                                                                          | Positive                                                                                                  | Negative | Inconclusive | Not | Using the list |
| Tested                                                 | provided,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              |                                                                                                                                                               |                                                                                                           |          |              |     |                |  
| indicate whether  the patient had  any coinfections by  providing the  results of each  of the tests  listed.                                                                                                                                                                                                                                                            |                                                                                                                                                                                                                                                                                                                                 |                                                                                                                                                                                       |    |    |         |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----|----|---------|
| HBV                                                                                                                                                                                                                                                        |                                                                                                                                                                                                                                                                                                                                |                                                                                                                                                                                      |   |   | 2180456 |
| HCV                                                                                                                                                                                                                                                        |                                                                                                                                                                                                                                                                                                                                |                                                                                                                                                                                      |   |   | 2695021 |
| HPV                                                                                                                                                                                                                                                        |                                                                                                                                                                                                                                                                                                                                |                                                                                                                                                                                      |   |   | 2230033 |
| KSHV/HHV8                                                                                                                                                                                                                                                  |                                                                                                                                                                                                                                                                                                                                |                                                                                                                                                                                      |   |   | 3335773 |
| Indicate whether the patient received Highly  Active Antiretroviral Therapy (HAART)  treatment prior to the diagnosis of the  malignancy submitted for the BLGSP study. 3335156                                                                            |                                                                                                                                                                                                                                                                                                                                 |                                                                                                                                                                                       |    |    |         |
| HAART Treatment  Prior to Diagnosis of  Submitted  Malignancy                                                                                                                                                                                              |  Yes  No  Unknown                                                                                                                                                                                                                                                                                                            |                                                                                                                                                                                       |    |    |         |
| 47                                                                                                                                                                                                                                                         | HAART Treatment  at Time of  Diagnosis of  Submitted  Malignancy                                                                                                                                                                                                                                                                | Indicate whether the patient received Highly  Active Antiretroviral Therapy (HAART)  treatment at the time of the diagnosis of the  malignancy submitted for the BLGSP study. 2922679 |    |    |         |
|  Yes  No  Unknown                                                                                                                                                                                                                                       |                                                                                                                                                                                                                                                                                                                                 |                                                                                                                                                                                       |    |    |         |
| 48                                                                                                                                                                                                                                                         |  Homosexual or bisexual contact  Heterosexual contact  IV drug user  Transfusion recipient  Hemophiliac  Unknown                                                                                                                                                                                                          | Indicate whether the patient has a history of any  of the listed HIV Risk Groups as defined by the  Center for Disease Control (CDC). 2542215                                         |    |    |         |
| 49                                                                                                                                                                                                                                                         | CDC HIV Risk  Group(s)                                                                                                                                                                                                                                                                                                          |                                                                                                                                                                                       |    |    |         |
| Prior Malignancies                                                                                                                                                                                                                                         | Indicate whether the patient has a history of  malignancies, including synchronous or  bilateral malignancies.  3382736 If the answer to this question is "yes", the  submitted case is excluded. This exclusion does  not apply if the patient only has a history of  non-melanoma skin cancer OR cervical in situ  carcinoma. |                                                                                                                                                                                       |    |    |         |
| Prior Immunological Disease *50 History of other   Yes (exclusion criterion) malignancy   No  Rheumatoid Arthritis  Sjogren's Syndrome  Systemic Lupus Erythematous  Crohn's Disease  Ulcerative Colitis  Hasimoto's Thyroiditis  Other  Unknown | Indicate whether the patient has a history of any  of the listed immunological diseases. 3233628                                                                                                                                                                                                                                |                                                                                                                                                                                       |    |    |         |
| Patient History of                                                                                                                                                                                                                                         |                                                                                                                                                                                                                                                                                                                                 |                                                                                                                                                                                       |    |    |         |
| 51                                                                                                                                                                                                                                                         | Prior Immunological  Disease Other Specified  Patient History of  Immunological  Disease Only complete if                                                                                                                                                                                                                       | Indicate whether the patient has a history of any  of the listed immunological diseases. 3233629                                                                                      |    |    |         |
| 52                                                                                                                                                                                                                                                         | ______________________________                                                                                                                                                                                                                                                                                                  |                                                                                                                                                                                       |    |    |         |  
| "other" is selected in  #5.                                                       |  Methotrexate  Cyclophosphamide  Azathioprine  Anti-TNF therapy  None  Other  Unknown                                            | If the patient received immunosuppressive  therapy for the immunological disease selected  in the previous question, provide the type of  immunosuppressive therapy given. 3233638   |
|-----------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Patient History of  Prior  Immunosuppressive  Therapy for  Immunological  Disease |                                                                                                                                         |                                                                                                                                                                                      |
| 53                                                                                | Other Prior  Immunosuppressive  Therapy  Administered  Specify Text Only complete if  "other" is selected in  #5.                       | What was the other immunosuppressive therapy  administered?  2873928                                                                                                                 |
| 54                                                                                | ___________________________                                                                                                             |                                                                                                                                                                                      |
| Prior Infectious Disease                                                          |  Hepatitis B  Hepatitis C  H. Pylori  Malaria  Other  Unknown                                                                     | Indicate whether the patient has a history of any  of the listed infectious disease. 3233642                                                                                         |
| Patient History of                                                                |                                                                                                                                         |                                                                                                                                                                                      |
| 55                                                                                | Relevant Prior  Infectious Disease Patient History of  Other Relevant  Infectious Disease Only complete if  "other" is selected in  #5. | If the patient has a history of relevant prior  disease that was not included in the list, provide  the infectious disease. 3233643                                                  |
| 56                                                                                | ____________________________                                                                                                            |                                                                                                                                                                                      |
| Pathologic Information                                                            |  Burkitt Lymphoma (BL), classic morphology  Burkitt Lymphoma (BL), atypical morphology  Other, specify  Unknown                     | Using the patient's final diagnostic pathology  report, provide the most detailed histological  subtype available.  3081934                                                          |
| *57                                                                               | Histological  Subtype Other Neoplasm  Histologic Type,  Specify Only complete if  "other" is selected in  #5.                           | Free text field to specify the structural pattern  of cancer cells used to define a microscopic  diagnosis that is not already specified or  mentioned. 3294805                      |
| 58                                                                                | _____________________________                                                                                                           | Using the pathology report, indicate the  percentage of the follicular component within  the Burkitt lymphoma sample that was  removed from the patient. 3770422                     |
|  <=10%  > 10% (exclusionary)  Unknown                                          |                                                                                                                                         |                                                                                                                                                                                      |
| *59                                                                               | Percent Follicular  Component                                                                                                           |                                                                                                                                                                                      |  
| Using the patient's medical record check all  applicable boxes to identify the lymph node  chain(s) that were involved by Burkitt  lymphoma at the time of initial diagnosis. 2180591 To select multiple sites of involvement, press  the control button and select the sites of  involvement. Your selections should be  highlighted after you've selected.                                  |                                                                                                                                              |                                                                                                                                                                                                                                                                                                                                                                                   |
|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
|  Occipital  Paraaortic  Parotid  Popliteal  Retroperitoneal  Splenic  Supraclavicular  Submandibular                                                                                                                                                                                                                                                                                  |                                                                                                                                              |                                                                                                                                                                                                                                                                                                                                                                                   |
|  Axillary  Cervical  Epitrochlear  Femoral  Hilar  Iliac  Iliac-common  Iliac-external  Mediastinal  Mesenteric                                                                                                                                                                                                                                                                     |                                                                                                                                              |                                                                                                                                                                                                                                                                                                                                                                                   |
| Site(s) of Nodal  Involvement at  Diagnosis (Please check all  that apply)                                                                                                                                                                                                                                                                                                                    |                                                                                                                                              |                                                                                                                                                                                                                                                                                                                                                                                   |
| *60                                                                                                                                                                                                                                                                                                                                                                                           |  No known nodal  involvement Gastrointestinal/  Abdominal  Ascites  Appendix  Colon  Esophagus  Gallbladder  Liver  Pancreas  Rectum  Small Intestine  Stomach Genito-urinary  Tract  Bladder  Epididymis  Kidney  Ovary  Prostate  Testicle  Uterus Mediastinal/ Intrathoracic  Heart  Lung  Mediastinal Soft  Tissue  Pericardium  Pleura                                                                                                                                              | Using the patient's medical record check all  applicable boxes to identify the anatomic  location of all site(s) of extranodal involvement  by Burkitt lymphoma at the time of initial  diagnosis. 2735776 To select multiple sites of involvement, press  the control button and select the sites of  involvement. Your selections should be  highlighted after you've selected. |
|  Adrenal Gland  Bone  Bone Marrow  Breast  Peripheral Blood  Skin  Soft Tissue (muscle,  ligaments, subcutaneous) ENT & Eye  Eye  Larynx  Mandible  Maxilla  Nasal Soft Tissue  Nasopharynx  Ocular orbits  Oropharynx  Parotid Gland  Peri-orbital Soft Tissue  Salivary Gland  Sinus(es)  Thyroid gland Central Nervous System  Brain  Epidural space  Leptomeninges |                                                                                                                                              |                                                                                                                                                                                                                                                                                                                                                                                   |
| Site(s) of Extranodal  Involvement At Diagnosis (Please check all  that apply)                                                                                                                                                                                                                                                                                                                |                                                                                                                                              |                                                                                                                                                                                                                                                                                                                                                                                   |
| *61                                                                                                                                                                                                                                                                                                                                                                                           |  Not applicable  Other, please  specify                                                                                                    |                                                                                                                                                                                                                                                                                                                                                                                   |
| Other Specified Site  of Extranodal  Involvement at  Diagnosis (For Primary  Clinical  Involvement)                                                                                                                                                                                                                                                                                           | If all extranodal sites of involvement are not  included in the list provided, please indicate  any sites of extranodal involvement. 3234303 |                                                                                                                                                                                                                                                                                                                                                                                   |
| 62                                                                                                                                                                                                                                                                                                                                                                                            | ____________________________                                                                                                                 |                                                                                                                                                                                                                                                                                                                                                                                   |  
| Provide the total number of extranodal sites  with lymphoma involvement. Use the previous  three questions to determine this number. This  information, along with other data provided,  will be used by the Analysis Working Group  (AWG) to calculate the International Prognostic  Index (IPI).  3233242                                                                                                                                                                                                            |                              |                                                                                                                                                      |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------|
| Number of  Extranodal Sites of  Involvement Above  (to calculate the IPI)                                                                                                                                                                                                                                                                                                                                                                                                                                              |                              |                                                                                                                                                      |
| 63                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     | ____________________________ | After review of the entire medical record,  record the length of the largest dimension/  diameter of a tumor, regardless of anatomical  plane. 64215 |
| Maximum Tumor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          |                              |                                                                                                                                                      |
| 64                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     | Bulk                         | ____________________________ (cm)                                                                                                                    |
| (Dimension)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            | Gastrointestina l/ Abdominal  Ascites/  Peritoneum  Appendix  Colon  Esophagus  Liver  Pancreas  Rectum  Small  Intestine  Stomach Central  Nervous  System  Brain  Epidural  Lepomeninges Lymph Nodes  Axillary  Cervical  Epitrochlear  Femoral  Ililac  Iliaccommon  Iliac-external  Mediastinal  Mesenteric  Occipital  Paraaortic  Parotid  Popliteal  Retroperitoneal  Splenic  Supraclavicular  Submandibular                              | Using the list of sites in numbers 39 and 40,  provide the anatomic site of the maximum  tumor bulk. 3233300                                         |
|  Adrenal  Bone  Bone Marrow  Brest  Peripheral Blood  Skin  Soft Tissue (muscle,  ligaments, subcutaneous) Genito-urinary Tract  Epididymis  Kidney  Ovary  Prostate  Testes  Uterus ENT & Eye  Intraocular  Larynx  Nasal Soft Tissue  Nasopharynx  Oropharynx  Parotid Gland  Peri-orbital Soft Tissue  Salivary Gland  Sinus  Thyroid Mediastinal/ Intra-thoracic  Heart  Lung  Mediastinal Soft Tissue  Pericardium  Pleura  Other, please specify  No Known Extranodal  Involvement |                              |                                                                                                                                                      |
| Anatomic Site of  Maximum Tumor  Bulk (Select one  anatomic site from  listing above)                                                                                                                                                                                                                                                                                                                                                                                                                                  |                              |                                                                                                                                                      |
| *65                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    |                              |                                                                                                                                                      |  
|  No Known  Nodal  Involvement                                                                                                |                                                                                                                                                                                                                                                                                                                                |                                                                                                                     |                                                                                                                       |                                                                                                                                                                                                                                                                                                                                                          |
|-------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Pathologic Diagnosis and Surgical Resection                                                                                   | Provide the date the patient was initially  diagnosed with the malignancy submitted for  BLGSP. This may or may not be the date of the  surgical resection that yielded the tumor sample  submitted for BLGSP. 2896956 (month), 2896958 (day),  2896960 (year) Note: The day of Initial Pathologic Diagnosis is  not required. |                                                                                                                     |                                                                                                                       |                                                                                                                                                                                                                                                                                                                                                          |
| Date of Initial                                                                                                               |                                                                                                                                                                                                                                                                                                                                |                                                                                                                     |                                                                                                                       |                                                                                                                                                                                                                                                                                                                                                          |
| *66                                                                                                                           | Pathologic  Diagnosis                                                                                                                                                                                                                                                                                                          | ____ ____ /                                                                                                         | ____ ____ /                                                                                                           | ___ ___ ___ ___                                                                                                                                                                                                                                                                                                                                          |
| (month)                                                                                                                       | (day)                                                                                                                                                                                                                                                                                                                          | (year)                                                                                                              | Provide the method of the initial pathologic  diagnosis. This is the method used on the date  provided above. 2757941 |                                                                                                                                                                                                                                                                                                                                                          |
|  Incisional Biopsy  Excisional Biopsy   Core Biopsy  Blood Draw  Bone Marrow Aspirate  Other (please specify)  Unknown |                                                                                                                                                                                                                                                                                                                                |                                                                                                                     |                                                                                                                       |                                                                                                                                                                                                                                                                                                                                                          |
| Initial Pathologic                                                                                                            |                                                                                                                                                                                                                                                                                                                                |                                                                                                                     |                                                                                                                       |                                                                                                                                                                                                                                                                                                                                                          |
| 67                                                                                                                            | Diagnosis  Acquisition Method                                                                                                                                                                                                                                                                                                  | If the method of initial pathologic diagnosis is  not included in the list above, provide the  method used. 2757948 |                                                                                                                       |                                                                                                                                                                                                                                                                                                                                                          |
| Other Method of                                                                                                               |                                                                                                                                                                                                                                                                                                                                |                                                                                                                     |                                                                                                                       |                                                                                                                                                                                                                                                                                                                                                          |
| 68                                                                                                                            | Initial Pathologic                                                                                                                                                                                                                                                                                                             | ____________________________                                                                                        |                                                                                                                       |                                                                                                                                                                                                                                                                                                                                                          |
| Diagnosis                                                                                                                     | Provide the date of the surgical resection that  yielded the tumor sample submitted for  BLGSP. 3008197 (month), 3008195 (day),  3008199 (year)                                                                                                                                                                                |                                                                                                                     |                                                                                                                       |                                                                                                                                                                                                                                                                                                                                                          |
| Staging and Histology of Bone Marrow 69 Date of Tumor  ____ ____ /                                                            | ____ ____ /                                                                                                                                                                                                                                                                                                                    | ___ ___ ___ ___                                                                                                     |                                                                                                                       |                                                                                                                                                                                                                                                                                                                                                          |
| Collection                                                                                                                    | (month)                                                                                                                                                                                                                                                                                                                        | (day)                                                                                                               | (year)                                                                                                                | Using the Ann Arbor criteria, provide the stage  that was used to treat the patient. 2902417 A: Absence of the Ann Arbor staging system  symptoms including fevers, night sweats, and  weight loss. B: Presence of the Ann Arbor staging system  symptoms including fevers, night sweats, and  weight loss. E: Presence of lymphoma in extranodal sites. |
|  Stage IA                                                                                                                    |  Stage IIIA                                                                                                                                                                                                                                                                                                                   |                                                                                                                     |                                                                                                                       |                                                                                                                                                                                                                                                                                                                                                          |
|  Stage IB                                                                                                                    |  Stage IIIB                                                                                                                                                                                                                                                                                                                   |                                                                                                                     |                                                                                                                       |                                                                                                                                                                                                                                                                                                                                                          |
|  Stage IE                                                                                                                    |  Stage IIIE                                                                                                                                                                                                                                                                                                                   |                                                                                                                     |                                                                                                                       |                                                                                                                                                                                                                                                                                                                                                          |
| *70                                                                                                                           | Tumor Stage                                                                                                                                                                                                                                                                                                                    |  Stage IIA                                                                                                         |  Stage IVA                                                                                                           |                                                                                                                                                                                                                                                                                                                                                          |
|  Stage IIB                                                                                                                   |  Stage IVB                                                                                                                                                                                                                                                                                                                    |                                                                                                                     |                                                                                                                       |                                                                                                                                                                                                                                                                                                                                                          |
|  Stage IIE                                                                                                                   |  Stage IVE                                                                                                                                                                                                                                                                                                                    | Indicate if malignant cells are histologically  confirmed in the patient's bone marrow. 2180550                     |                                                                                                                       |                                                                                                                                                                                                                                                                                                                                                          |
| Presence of  Malignant Cells in  Bone Marrow by  Histology                                                                    |  Yes  No  Unknown                                                                                                                                                                                                                                                                                                           |                                                                                                                     |                                                                                                                       |                                                                                                                                                                                                                                                                                                                                                          |
| 71                                                                                                                            | If malignant cells are present in the bone  marrow at the time of initial staging workup,  determine if the histologic diagnosis of the  bone marrow is concordant with the diagnosis                                                                                                                                          |                                                                                                                     |                                                                                                                       |                                                                                                                                                                                                                                                                                                                                                          |
|  Concordant Histology  Discordant Histology  Unknown                                                                       |                                                                                                                                                                                                                                                                                                                                |                                                                                                                     |                                                                                                                       |                                                                                                                                                                                                                                                                                                                                                          |
| 72                                                                                                                            | Histology of Bone  Marrow Samples                                                                                                                                                                                                                                                                                              |                                                                                                                     |                                                                                                                       |                                                                                                                                                                                                                                                                                                                                                          |  
| of BL. 3233401                                           |                                                 |                                                                                                                      |                                                                                                                                                  |                                                                                                                                      |    |                                                                                                                        |                                                                                         |    |
|----------------------------------------------------------|-------------------------------------------------|----------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------|----|------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------|----|
| Tests Performed LDH Level (at the time of staging)       | Record the result of the LDH lab test performed |                                                                                                                      |                                                                                                                                                  |                                                                                                                                      |    |                                                                                                                        |                                                                                         |    |
| *73                                                      | LDH Level                                       | ____________________________(IU)                                                                                     | during the staging workup. 2798766 Record the upper limit of the normal range of  the LDH lab test performed at the reporting  facility. 2953115 |                                                                                                                                      |    |                                                                                                                        |                                                                                         |    |
| Genetic Testing LDH Level Upper  *74 Limit for Normal at | ____________________________(IU)                |                                                                                                                      |                                                                                                                                                  |                                                                                                                                      |    |                                                                                                                        |                                                                                         |    |
| Facility                                                 | (+)                                             | (-)                                                                                                                  | Indeterminate                                                                                                                                    | Indicate all tests  performed for  immunophenotypic  analysis in order to  classify clonal subgroups. 3234614, 3234626               |    |                                                                                                                        |                                                                                         |    |
| Ki-67 > 90%                                              |                                                |                                                                                                                     |                                                                                                                                                 |                                                                                                                                      |    |                                                                                                                        |                                                                                         |    |
| CD10 > 30%                                               |                                                |                                                                                                                     |                                                                                                                                                 |                                                                                                                                      |    |                                                                                                                        |                                                                                         |    |
| BCL2                                                     |                                                |                                                                                                                     |                                                                                                                                                 |                                                                                                                                      |    |                                                                                                                        |                                                                                         |    |
| CD20                                                     |                                                |                                                                                                                     |                                                                                                                                                 |                                                                                                                                      |    |                                                                                                                        |                                                                                         |    |
| BCL6 > 30%                                               |                                                |                                                                                                                     |                                                                                                                                                 |                                                                                                                                      |    |                                                                                                                        |                                                                                         |    |
| CD3                                                      |                                                |                                                                                                                     |                                                                                                                                                 |                                                                                                                                      |    |                                                                                                                        |                                                                                         |    |
| 75                                                       | Immunophenotypin g                              | Indicate all tests performed for  immunophenotypic analysis in order to classify  clonal subgroups. 3234626, 2516429 |                                                                                                                                                  |                                                                                                                                      |    |                                                                                                                        |                                                                                         |    |
| Other                                                    |                                                 |                                                                                                                      |                                                                                                                                                  |                                                                                                                                      |    |                                                                                                                        |                                                                                         |    |
| 76                                                       | Immunophenotypin g (please specify)             |  Immunohistochemistry  Flow Cytometry, not otherwise specified  Immunofluorescence  Other                        | If B-cell genotype was performed, indicate the  testing method used. 64540                                                                       |                                                                                                                                      |    |                                                                                                                        |                                                                                         |    |
| B-cell                                                   |                                                 |                                                                                                                      |                                                                                                                                                  |                                                                                                                                      |    |                                                                                                                        |                                                                                         |    |
| 77                                                       | Immunophenotype  Methodology                    |                                                                                                                      |                                                                                                                                                  |                                                                                                                                      |    |                                                                                                                        |                                                                                         |    |
| Genetic Abnormalities                                    | N                                               | T                                                                                                                    | G                                                                                                                                                | A                                                                                                                                    | L  | O                                                                                                                      | Indicate all genetic  abnormalities for which  the patient was tested. 3234675, 3234680 |    |
| C-MYC                                                    |                                                |                                                                                                                     |                                                                                                                                                 |                                                                                                                                     |   |                                                                                                                       |                                                                                         |    |
| 78                                                       | Genetic  Abnormalities                          | N = Normal T = Translocation G = Gain L = Loss A = Amplification O = Other                                           |                                                                                                                                                  |                                                                                                                                      |    |                                                                                                                        |                                                                                         |    |
| BCL2                                                     |                                                |                                                                                                                     |                                                                                                                                                 |                                                                                                                                     |   |                                                                                                                       |                                                                                         |    |
| BCL6                                                     |                                                |                                                                                                                     |                                                                                                                                                 |                                                                                                                                     |   |                                                                                                                       |                                                                                         |    |
| N                                                        | T                                               | G                                                                                                                    | A                                                                                                                                                | L                                                                                                                                    | O  | Specify any other genetic  abnormalities not in the  provided list for which the  patient was tested. 3234685, 3234680 |                                                                                         |    |
| ________                                                 |                                                |                                                                                                                     |                                                                                                                                                 |                                                                                                                                     |   |                                                                                                                       |                                                                                         |    |
| Other Genetic                                            |                                                 |                                                                                                                      |                                                                                                                                                  |                                                                                                                                      |    |                                                                                                                        |                                                                                         |    |
| 79                                                       | Abnormalities  (please specify)                 | ________                                                                                                             |                                                                                                                                                 |                                                                                                                                     |   |                                                                                                                       |                                                                                        |   |
| ________                                                 |                                                |                                                                                                                     |                                                                                                                                                 |                                                                                                                                     |   |                                                                                                                       |                                                                                         |    |
| ________                                                 |                                                |                                                                                                                     |                                                                                                                                                 |                                                                                                                                     |   |                                                                                                                       |                                                                                         |    |
| 1                                                        | 2                                               | 3                                                                                                                    | 4                                                                                                                                                | If the patient was tested  for a specific genetic  abnormality, indicate the  testing method used to  perform each analysis. 3234684 |    |                                                                                                                        |                                                                                         |    |
| Methodology Used                                         |                                                 |                                                                                                                      |                                                                                                                                                  |                                                                                                                                      |    |                                                                                                                        |                                                                                         |    |
| 80                                                       | to Identify Genetic  Abnormalities              | C-MYC                                                                                                                |                                                                                                                                                 |                                                                                                                                     |   |                                                                                                                       |                                                                                         |    |
| BCL2                                                     |                                                |                                                                                                                     |                                                                                                                                                 |                                                                                                                                     |    |                                                                                                                        |                                                                                         |    |
| BCL6                                                     |                                                |                                                                                                                     |                                                                                                                                                 |                                                                                                                                     |    |                                                                                                                        |                                                                                         |    |  
| Methodology Code: 1 = PCR 2 = Southern Blot 3 = FISH 4 = Cytogenetic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            |                                                                                                                                     |                                                                                                                                                                |
|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------|
| If the patient was tested for a specific genetic abnormality,  indicate the testing method used to perform each analysis. 3234684                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               |                                                                                                                                     |                                                                                                                                                                |
| Methodology Used  to Identify Other  Genetic  Abnormalities                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     |                                                                                                                                     |                                                                                                                                                                |
| 81                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              | Methodology Code: 1 = PCR 2 = Southern Blot 3 = FISH 4 = Cytogenetic                                                                |                                                                                                                                                                |
|  Positive  Negative  Unknown                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 | Provide the result of the lab test to detect the presence of  Epstein/Barr Virus antibody in the patient. 2003961                   |                                                                                                                                                                |
| 82                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              | EBV Status of  Malignant Cells If EBV status is  positive, provide the  percent positive. (does not include  background  positives) | If the patient's EBV status was positive, provide the  percentage of EBV positive malignant cells. Do not include  the number of background positives. 3233649 |
| 83                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              | ________________________(%)                                                                                                         | If the patient's EBV status was positive, provide the testing  method used to determine the EBV status of the malignant  cells. 3233656                        |
| New Tumor Event Information Complete this section if the patient had a new tumor event. If the patient did not have a new  tumor event (or if the TSS does not know) indicate this in the question below, and the  remainder of this section can be skipped. Note: The New Tumor Event section on OpenClinica can be completed multiple times, if the patient had multiple New Tumor  Events. First Recurrence or Progression Methodology Used  to Determine EBV  Status of Malignant  Cells  EBER in situ Hybridization  LMP Immunohistochemistry  EBV PCR  Unknown 84 Has the patient  developed a  first relapse or  progression  that has not  been  previously  reported? Indicate whether the patient has been diagnosed  with a first recurrence or progression. 2002502  Yes  No  Unknown 85* Provide the date documenting the initial  identification of reappearance or advancement  in extent or severity of cancer.  62998 Date of First  86 Recurrence or  __ __ / __ __ / __ __ __ __ Progression  Locoregional Recurrence   Locoregional Disease  Distant Metastasis  Recurrence  New Primary Tumor Indicate whether the patient's new tumor event  was a locoregional recurrence, a distant  metastasis, or a new primary tumor. 3119721 87 Type of New  Tumor Event Site of First  88 Malignant  Lymphoma   Adrenal   Appendix  Ascites/ Peritoneum  Nasal Soft  Tissue  Nasopharynx Description of the anatomic location of  progression of disease for malignant  lymphoma. |                                                                                                                                     |                                                                                                                                                                |  
| Progression   |  Axillary lymph nodes  Bone  Bone Marrow  Brain  Breast  Cervical lymph nodes  Colon  Conjunctiva  Epididymis  Epidural  Epitrochlear lymph nodes  Esophagus  Femoral lymph nodes  Gastrointestinal/ Abdominal  Heart  Hilar lymph nodes  Iliac-common lymph nodes  Iliac-external lymph nodes  Inguinal lymph nodes  Intraocular  Kidney  Large intestine  Larynx  Leptomeninges  Liver  Lung  Mandible  Maxilla  Mediastinal/ Intrathoracic  Mediastinal lymph nodes  Mediastinal soft tissue  Mesenteric lymph nodes   |  Occipital  lymph nodes  Orbit  Oropharynx  Ovary  Pancreas  Paraaortic  lymph nodes  Parotid  Gland  Parotid  lymph nodes  Peri-orbital  Soft Tissue  Pericardium  Peripheral  Blood  Pleura/  Pleural  Effusion  Popliteal  lymph nodes  Prostate  Rectum  Retroperiton eal lymph  nodes  Salivary  Gland  Sinus  Skin  Small  Intestine  Soft Tissue  (muscle,  ligaments,  subcutaneous )  Splenic  lymph nodes  Stomach  Submandibul ar lymph  nodes  Supraclavicu lar lymph  nodes  Testes  Thyroid  Uterus  No known  extranodal  3282650   |
|---------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|  
| involvement                                                                                                                                                                                            |                                                                                                                                                                                              |                                                                                                                                                |                                                                                                                             |               |
|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------|---------------|
|  Other  Extranodal  Site                                                                                                                                                                              |                                                                                                                                                                                              |                                                                                                                                                |                                                                                                                             |               |
| Other Specified  Extranodal Site  of First  Malignant  Lymphoma  Progression                                                                                                                           | If the patient had a new tumor event and the  site of this tumor was not included in the  provided list, describe the site.  3282651                                                         |                                                                                                                                                |                                                                                                                             |               |
| 89                                                                                                                                                                                                     | ____________________________________                                                                                                                                                         |                                                                                                                                                |                                                                                                                             |               |
| Was Site of  First  Progression  Biopsied?                                                                                                                                                             | If the patient has had progression of disease,  indicate whether the site of first progression  was biopsied. 2716366                                                                        |                                                                                                                                                |                                                                                                                             |               |
|  Yes  No  Unknown                                                                                                                                                                                   |                                                                                                                                                                                              |                                                                                                                                                |                                                                                                                             |               |
| 90                                                                                                                                                                                                     | If biopsied,  what was the  Histological  Subtype?                                                                                                                                           |  Burkitt lymphoma, classic morphology  Burkitt lymphoma, atypical morphology  Other Histological Type, specify  Unknown                    | Using the patient's final diagnostic pathology  report, provide the most detailed histological  subtype available.  3282652 |               |
| *91                                                                                                                                                                                                    | Specify the structural pattern of malignant  lymphoma cells at the time of biopsy for first  progression of malignant lymphoma different  from those already specified or mentioned. 3282653 |                                                                                                                                                |                                                                                                                             |               |
| Additional New Tumor Events Other Specified  92 Histologic  _____________________________ Type Has the patient  developed a  second  progression or  relapse that has  not been  previously  reported? | Indicate whether the patient had a second  progression or relapse that has not been  previously reported.  3137510                                                                           |                                                                                                                                                |                                                                                                                             |               |
|  Yes  No  Unknown                                                                                                                                                                                   |                                                                                                                                                                                              |                                                                                                                                                |                                                                                                                             |               |
| *93                                                                                                                                                                                                    |  Locoregional Recurrence   Locoregional Disease  Distant Metastasis  Recurrence  New Primary Tumor  No new Tumor Event  Not applicable                                                | Indicate whether the patient's new tumor event  was a locoregional recurrence, a distant  metastasis, or a new primary tumor. 3119721          |                                                                                                                             |               |
| 94                                                                                                                                                                                                     | Type of New  Tumor Event                                                                                                                                                                     | If the patient had a new tumor event, provide  the date of diagnosis for this new tumor event. 3104044 (month), 3104042 (day),  3104046 (year) |                                                                                                                             |               |
| *95                                                                                                                                                                                                    | Date of New                                                                                                                                                                                  | ____ ____ /                                                                                                                                    | ____ ____ /                                                                                                                 | __ ___ ___ __ |
| Tumor Event                                                                                                                                                                                            | (month)                                                                                                                                                                                      | (day)                                                                                                                                          | (year)                                                                                                                      |               |  
| Indicate whether the patient was living or  deceased at the date of last contact, or has been  lost to follow-up as defined by the ACoS  Commission on Cancer. This only includes  cases where updated follow-up information has  not been collected within the past 15 months  and all efforts to contact the patient have been  exhausted (this includes reviewing death  records). If the patient is lost to follow-up, the  remaining questions can be left unanswered. If the patient is deceased and a BLGSP followup form has not yet been completed, the  remaining applicable questions should be  completed. 5                                                  |                                    |
|--------------------------------------------------|------------------------------------|
| Patient Vital  Status (at date of last  contact) |  Alive  Dead  Lost to follow-up |
| *96                                              |                                    |
| General Comments                                 |                                    |  
_____________________________________/________________________________________
Principal Investigator (*Printed Name*) Principal Investigator (*Signature*) Date I acknowledge that the above information provided by my institution is true and correct and has been quality controlled.