(Attach Label here or Complete Details)
NAME:___________________________________________________NHI:__________
GENDER: ____
HSCT Programme
Haematology
DOB:______________
AGE:______
WARD:________________
6 Month and Annual Assessment
Post-HSCT
This assessment needs to reflect the details since the last assessment was completed. Report the highest grades
ASSESSMENT DETAILS
Date of Transplant:
Date of This Assessment:
6 month assessment
4 yr assessment
12 month assessment
5 yr assessment
2 yr assessment
other, please state:
3 yr assessment
FUNCTIONAL STATUS
Occupation:
Karnovsky Scale:
Full-time
Part-time
Not Working
DISEASE STATUS
Complete Remission
Partial Remission
Stable Disease
Relapse
Date established:
Evidence:
Subsequent HSCT since last report?
Subsequent DLI since last report?
Yes
Yes
Clinical
Histological
Radiological
Minimal residual disease test
Answers to subsequent questions should reflect clinical
status immediately prior to start of preparative regime for
subsequent HSCT
No
No
COUNT RECOVERY
complete this section if patient did not recovery during previous assessment
Record first of 3 consecutive days
Record how many days post-SCT
9
Date:
Date:
Neutrophils ≥ 0.5 x 10 /L
9
Neutrophils ≥ 1.0 x 10 /L
Day +
Day +
Record first of 3 consecutive days without transfusion in previous 7 days
9
Date:
Date:
Platelet ≥ 20 x 10 /L
9
Platelet ≥ 50 x 10 /L
Record how many days post-SCT
Day +
Day +
SUBSEQUENT COUNT INFORMATION
Following neutrophil recovery, has there been a subsequent decline in
9
neutrophils to < 0.5 x 10 /L for ≥ 3 days since date of last report?
Yes
No
Date of decline:
Date of last red cell transfusion:
Date of most recent CBC & Diff:
Date of last platelet transfusion:
POST-TRANSPLANT DETAILS SINCE LAST ASSESSMENT REPORT
Were Immunoglobulins Tested?
Yes values:
Has IVIG been given?
Yes
No
Indications for use:
prophylaxis for CMV
low IgG (no infection)
Other,
Were therapies ongoing within 1 month of IVIG?
No
treatment for CMV
RSV infection
low IgG (with infection, but not CMV or RSV)
Yes
No
Date of most recent lymphocyte analyses:
Chimerism Studies:
Yes
No
Date of Chimerism:
CMV Status:
Engraftment Syndrome?
Yes
No
Date & Symptoms:
Clinical Significant Infections:
(include organism)
Ref: 5005
Authorised By: Programme Director
Page 1 of 5
Version: 1
Issue Date: January 2014
(Attach Label here or Complete Details)
Assessment
Post-HSCT
NAME:___________________________________________________ NHI:__________
GENDER: ____
DOB:______________
AGE:______
WARD:________________
Antibiotics:
Significant Organ Impairment:
(include investigations)
Current Medications:
Additional Issues/Advice:
GVHD ASSESSMENT
Did any GVHD develop or persist since last report?
Yes (complete applicable sections below)
No
Acute GVHD
Date of Onset:
Histological Evidence:
Yes
No
Clinical Evidence:
Is acute GVHD still present at date of contact?
Yes
No
Yes
No
Progressed to chronic
LIST MAXIMUM SEVERITY OF ORGAN INVOLVEMENT
Treatment therapy used:
Skin
Start & Stop Dates:
No symptoms/rash not attributable to GVHD
Stage 1 Maculopapular rash < 25% BSA
Stage 2 Maculopapular rash 25 – 50% BSA
Stage 3 Generalised erythroderma
Stage 4 Generalised erythroderma with bullae formation and desquamation
Gut (lower intestinal tract)
Treatment therapy used:
Start & Stop Dates:
Symptoms not attributable to GVHD
Stage 0 No diarrhoea
Stage 1 Abdominal pain without significant weight loss (<5%). Diarrhoea ≥ 500ml/day but ≤ 1000ml/ day
Stage 2 Mild to moderate weight loss (5-15%) Diarrhoea > 1000ml.day but ≤ 1500ml/day
Stage 3 Significant weight loss > 15% Diarrhoea > 1500ml/day
Stage 4 Severe abdominal pain with or without ileus
Upper Intestinal Tract
Treatment therapy used:
Start & Stop Dates:
Stage 0 No persistent nausea or vomiting
Stage 1 Persistent nausea or vomiting
Liver
Treatment therapy used:
No liver acute GVHD / bilirubin level not attributable to acute GVHD
Stage 0 Bilirubin < 2.0 mg/dL (< 34 µmol/L)
Stage 1 Bilirubin 2.0 – 3.0 mg/dL (34 – 52 µmol/L)
Stage 2 Bilirubin 3.1 – 6.0 mg/dL (53 – 103 µmol/L)
Stage 3 Bilirubin 6.1 – 15.0 mg/dL (104 – 256 µmol/L)
Stage 4 Bilirubin > 15.0 mg/dL (> 256 µmol/L)
Other Organ Involvement:
Yes
No
Start & Stop Dates:
Organ Involved:
Date of Onset:
Maximum overall grade (Glucksberg):
Grade I (mild) Skin stage 1 or 2 only (no liver or gut aGVHD)
Grade II (moderate) Up to stage 1 liver or gut, up to stage 3 skin
Grade III (severe) Up to stage 4 liver, up to stage 3 in any other organ
Grade IV (life threatening) Stage 4 skin or gut, ECOG/WHO performance status 4 or Karnofsky performance
score < 30%
Ref: 5005
Authorised By: Programme Director
Page 2 of 5
Version:1
Issue Date: January 2014
(Attach Label here or Complete Details)
Assessment
Post-HSCT
NAME:___________________________________________________ NHI:__________
GENDER: ____
DOB:______________
AGE:______
WARD:________________
Chronic GVHD
Did chronic GVHD occur?
Date of onset:
GVHD Grade: Complete section A
Organ Involvement:
Yes
No
Progressed from acute GVHD
Histological Evidence OR
Clinical Evidence
Yes
No
If yes, complete Organ Scoring of GVHD, section B
Was specific therapy used to treat chronic GVHD?
If so, what was it & when did it start & stop:
New Malignancy?
Specify Organ:
YES
Yes
No
No
Date of onset:
PHYSICIAN PERFORMING ASSESSEMENT
Name:
Grade
Signed:
Date:
SECTION A: Overall chronic GVHD grade (NIH)
Organ Involvement
Mild
1 or 2 organs or sites (except the lung: see below), with no clinically significant functional impairment
(maximum of score 1 in all affected organs or sites)
Moderate
At least 1 organ or site with clinically significant but no major disability (maximum score of 2 in any
affected organ or site)
3 or more organs or sites with no clinically significant functional impairment (maximum score of 1 in all
affected organs or sites).
A lung score of 1 will also be considered moderate chronic GVHD.
Severe
Score of 3 in any organ or site.
A lung score of 2 or greater will also be considered severe chronic GVHD
SECTION B: Organ scoring of chronic GVHD
Performance
Score:
KPS
ECOG
LPS
SKIN
SCORE 0
SCORE 1
SCORE 2
SCORE 3
Asymptomatic and
fully active (ECOG 0;
KPS or LPS 100%)
Symptomatic, fully
ambulatory, restricted
only in physically
strenuous activity
(ECOG 1, KPS or LPS
80–90%)
<18% BSA with
disease signs but NO
sclerotic features
Symptomatic,
ambulatory, capable of
self-care, >50% of
waking hours out of
bed (ECOG 2, KPS or
LPS 60-70%)
19-50% BSA OR
involvement with
superficial sclerotic
features “not
hidebound” (able to
pinch)
Symptomatic,
limited self-care, >50%
of waking hours in bed
(ECOG 3-4, KPS or
LPS <60%)
No symptoms
Clinical features:
Maculopapular
rash
Lichen planus-like
features
Papulosquamous
lesions or ichthyosis
Hyperpigmentation
Hypopigmentation
Keratosis pilaris
Erythema
Erythroderma
Poikiloderma
Sclerotic features
Pruritus
Hair involvement
Nail involvement
>50% BSA OR
deep sclerotic features
“hidebound” (unable to
pinch) OR impaired
mobility, ulceration or
sever pruritus
%BSA involved:
Ref: 5005
Authorised By: Programme Director
Page 3 of 5
Version:1
Issue Date: January 2014
(Attach Label here or Complete Details)
Assessment
Post-HSCT
NAME:___________________________________________________ NHI:__________
GENDER: ____
DOB:______________
AGE:______
SCORE 0
WARD:________________
SCORE 1
SCORE 2
SCORE 3
MOUTH
No symptoms
Mild symptoms
with disease signs but
not limiting oral intake
significantly
Severe symptoms
with disease signs on
examination with major
limitation of oral intake
EYES
No symptoms
Mild dry eye
symptoms not affecting
ADL (requiring
eyedrops ≤ 3x per day)
OR asymptomatic
signs of
keratoconjunctivitis
sicca
Moderate
symptoms with
disease signs with
partial limitation of oral
intake
Moderate dry eye
symptoms partially
affecting ADL
(requiring drops >3 x
per day or punctal
plugs), WITHOUT
vision impairment
GI TRACT
No symptoms
Symptoms such as
dysphagia, anorexia,
nausea, vomiting,
abdominal pain or
diarrhoea without
significant weight loss
(<5%)
Symptoms
associated with mild to
moderate weight loss
(5 - 15%)
LIVER
Normal LFT
LUNGS†
No symptoms
Elevated Bilirubin,
AP*, AST or ALT <2 x
ULN
Mild symptoms
(shortness of breath
after climbing one flight
of steps)
Bilirubin >3 mg/dl
or Bilirubin, enzymes
2-5 x ULN
Moderate
symptoms (shortness
of breath after walking
on flat ground)
FEV1 60-79% OR
LFS 3-5
Mild tightness of
arms or legs, normal or
mild decreased range
of motion (ROM) AND
not affecting ADL
FEV1 40-59% OR
LFS 6-9
Tightness of arms
or legs OR joint
contractures, erythema
thought due to fasciitis,
moderate decrease
ROM AND mild to
moderate limitation of
ADL
Symptomatic with
moderate signs on
exam AND with mild
dyspareunia or
discomfort with
gynaecologic exam
Mean tear test (mm):
>10
6 - 10
≤5
Not done
FEV1:
DLCO:
JOINTS AND
FASCIA
GENITAL TRACT
FEV1 > 80% OR
LFS = 2
No symptoms
No symptoms
Symptomatic with
mild signs on exam
AND no effect on
coitus and minimal
discomfort with
gynaecologic exam
Severe dry eye
symptoms significantly
affecting ADL (special
eyeware to relieve
pain) OR unable to
work because of ocular
symptoms OR loss of
vision caused by
keratoconjunctivitis
sicca
Symptoms
associated with
significant weight loss
>15%, requires
nutritional supplement
for most calorie needs
OR oesophageal
dilation
Bilirubin or
enzymes >5 x ULN
Severe symptoms
(shortness of breath at
rest; requiring O2)
FEV1 ≤39% OR
LFS 10-12
Contractures WITH
significant decrease of
ROM AND significant
limitation of ADL
(unable to tie shoes,
button shirts, dress self
etc)
Symptomatic
WITH advanced signs
(stricture, labial
agglutination or severe
ulceration) AND
severe pain with coitus
or inability to insert
vaginal speculum
OTHER INDICATORS, clinical manifestations or complications related to chronic GVHD
check all that apply and assign a score to its severity (0 – 3) based on its functional impact where applicable (none – 0, mild 1, moderate – 2, severe – 3)
Oesophageal stricture or web:
Pericardial Effusion:
Pleural Effusion(s):
Ascites (serositis):
Nephrotic syndrome:
Peripheral Neuropathy:
M yasthenia Gravis:
Cardiomyopathy:
Eosinophilia > 500µl:
Polymyositis:
Cardiac conduction defects:
Coronary artery involvement:
Platelets <100,000/µl:
Progressive onset:
OTHERS: Specify:
Ref: 5005
Authorised By: Programme Director
Page 4 of 5
Version:1
Issue Date: January 2014
(Attach Label here or Complete Details)
NAME:___________________________________________________ NHI:__________
GENDER: ____
DOB:______________
AGE:______
WARD:________________
Assessment
Post-HSCT
Organ Scoring of chronic GVHD:
*AP may be elevated in growing children, and not reflective of liver dysfunction.
†
Pulmonary scoring should be performed using both the symptom and pulmonary function testing (PFT) scale whenever
possible. When discrepancy exists between pulmonary symptom or PFT scores the higher value should be used for final
scoring. Scoring using the Lung Function Score (LFS) is preferred, but if DLCO is not available, grading using FEV1 should be
used. The LFS is a global assessment of lung function after the diagnosis of bronchiolitis obliterans has already been
established. The percent predicated FEV1 and DLCO (adjusted for haematocrit but not alveolar volume) should be converted
to a numeric score as follows: >80% = 1; 70-79% = 2; 60-69% = 3; 50-59% = 4; 40-49% = 5; <40% = 6. The LFS = FELV1
score + DLCO score, with a possible range of 2-12. GVHD indicates graft versus host disease; ECOG, Eastern Cooperative
Oncology Group; KPS, Karnofsky Performance Status; LPS, Lansky Performance Status; BSA, body surface area; ADL,
activities of daily living; LFTs, liver function tests; AP, alkaline phosphatase; ALT, alanine aminotransferase; AST, aspirate
aminotransferase; ULN, upper limit of normal.
Chronic GVHD Risk Score
Arora, M., et al. (2011). "Chronic GVHD risk score: a Center for International Blood and Marrow Transplant Research analysis."
Blood 117(24): 6714-6720.
Risk Factor
0
1
2
Age (years)
<29
30-59
>60
Prior acute GVHD
None
Present
Time from transplantation to
cGVHD
>5 months
<5 months
<2 mg/dl
>2 mg/dl
</=34
>34
KPS at cGVHD onset
>/=80
<80
Platelet count at cGVHD onset
</=100
HLA-identical sibling
7/8 or 8/8 MUD
>100
Other
related/mismatched
MUD
Disease status at transplant**
Early
Intermediate
Sex mismatch (donor/recipient)
M/M, M/F, F/F
F/M
Serum bilirubin at cGVHD onset
Type of donor
Advanced
GVHD prophylaxis
CSA+MTX+other
Tacrolimus+MTX +other or TCD
**Early disease = allograft in CR1 (acute leukemia) or first chronic phase (CML) or MDS categories RA or RARS;
Intermediate disease = CR2 or later (ALL) or second chronic phase/accelerated phase or later (CML);
Advanced disease = patients in relapse or with refractory disease (acute leukemia) or blast crisis (CML) or MDS categories
RAEB or RAEB in transformation.
Score
Risk Group
OS (%)
NRM (%)
0–2
1
91
4.6
3-6
2
67
20
7-8
3
51
33
9 - 10
4
40
43
11
5
21
63
>12
>11
6
5+6
4
14.5
72
67
This prognostic scoring system for chronic graft versus host disease (cGVHD) was published by the Center for International
Blood and Marrow Transplant Research (CIBMTR) in 2011.1 It derives from a multivariate analysis of survival of 5343 patients
who underwent allogeneic stem cell transplantation from a related or unrelated donor (including umbilical cord blood) for AML,
ALL, CML, or MDS between 1995 and 2004, and who were diagnosed with cGVHD within 1 year of transplantation.
References: www.bloodref.com
Ref: 5005
Authorised By: Programme Director
Page 5 of 5
Version:1
Issue Date: January 2014