Outcomes of Multiple Myloma Patients Treated Across Pakistan
Hospital registration ID
Hospital name
Patient CNIC
Patient Contact No.
Patient Contact No. 2
Resource Environment
Limited
Enhanced
Age
Date of Birth
BMI
Gender
Male
Female
Weight
Height
BSA
Diagnosis date
Status
Transplant Eligible
Transplant Ineligible
ECOG
0
1
2
3
4
Marital Status
Married
Unmarried
Clinical Presentation
Back ache
Anemia
Azotemia
Pathological Fracture
Hyperlcalcemia
Other (if any)
Physical Examination
LABORATORY DATA
Hemoglobin g/dl
WBC (10^9/I)
Platelets (10^9/I)
ESR: mm fall
LDH:
Normal
High
Not Available
Serum Urea
Normal
High
Not Available
Serum Creatinine
Normal
High
Not Available
Serum Creatinine (umol/l) (if any)
Serum Calcium (mg/dl)
Serum bilirbin (mg/dl)
Serum ALT(IU/I)
Serum Alkaline Phosphate (IU/I)
Serum B2-microglobulin (mg/l)
Serum Albumin (g/dl)
Skeletal Survey Modality
x-ray
Whole body CT scan
MRI
PET scan
Findings on Skeletal Survey
Plasmacytoma
Yes
No
Plasmacytoma
Single
Multiple
Site of Plascytoma
Bone Marrow monoclonal plasma cell %
Serum LDH
Cytogentices
Serum protein electrophoresis result
Serum Immunofixation
Negative
Not Available
Heavy chain
lgG
lgM
lgA
lgG
Light Chain
Kappa
lambda
Urine Immunofixation Heavy Chain
lgG
lgM
lgA
lgD
Urine Immunofixation Light Chain
Kappa
lambda
Serum free Light Chain
Not Available
Abnormal value (if any)
Tumor Lysis Syndrome
Yes
No
HBV PCR
+ve
-ve
Not Available
HCV PCR
+ve
-ve
Not Available
HIV PCR
+ve
-ve
Not Available
Pregnancy
Yes
No
Not Available
Echocardiography EF%
Site of tissue diagnosis
Details of biopsy (Excisional/ tru-cut / other
Histological subtype
GCB
Non-GCB
Ki 67%
High grade BCL type
DEL/TEL
NOS
DHL
THL
Bone marrow involvement
Yes
No
Immunophenotyping (if done)
Cytogenetics (if done)
EBV-PCR (if done)
CNS involvement
Yes
No
LP findings
MRI findings
CNS Involvement
Leptomeningeal
Parenchymal
No Involvement
Cumulative index fraility score
Done
Not Done
Cumulative index fraility score
Disease characteristics and treatment response
IPI-Score
CNS-IPI
Ann-arbor stage
Staging modality
CT
PET-CT
FIRST LINE TREATMENT
First line regimen
CHOP
R-CHOP
Other
Other First line regimen (if any)
Dose adjustment done:
Yes
No
Date of Starting Treatment
Rituximab added to chemo from cycle no
Total number of rituximab doses given
No of chemo ± immuno Cycles at first line
CHOP
R-CHOP
Other (if any)
CNS prophylaxis
Yes
No
Type of CNS Prophylaxis
RESPONSE TO FIRST LINE CHEMO ± IMMUNOTHERAPY
Interim response assessment
Not done
CT
PET-CT
Interim response
CR
PR
SD
PD
End of treatment Date
End of treatment response assessment by
PET
CT
End of treatment response
CR
PR
SD
PD
RADIOTHERAPY
RT Indication
RT Dose
RT Site
Response post RT
CR
PR
SD
PD
Relapse/Refractory Cases
Refractory
Yes
No
Relapsed
Yes
No
Date of Relapse
Duration of CR from End of treatment
Repeat biopsy
Done
Not Done
Salvage regimen
Number of cycle of savalge
Side Effects
Response to salvage
CR
PR
SD
PD
HSCT
Consolidation auto-HSCT
Yes
No
Disease state at HSCT
CR
PR
SD
PD
Conditioning chemotherapy
Relapsed post Auto-HSCT
Yes
No
Duration of CR (months) post Auto
Allogenic HSCT
Done
Not Done
Not Applicable
Outcomes of Allogenic HSCT
CR
Relapsed
Death
Current Status
Date of last assessment
Alive CR
Alive relapsed
Dead
Lost to follow-up
Left against medical advice
Cause of death
Lymphoma related
Other
Other
Submitted by:
Name
Email
Phone No.
Institute/Organization
Supervised by:
Supervisor's Name
Supervisor's Email
Supervisor's Phone No.
Supervisor's Imstitution
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