Table 2.
The University of Chicago Hereditary Hematopoietic Malignancies Screening Form
| Hereditary Hematologic Malignancies Screening Form | |
|---|---|
| Step 1 | |
| Draw the family pedigree using standard symbols | |
| Step 2 | |
| Use screening questions to guide workup (see Table 1 for specific syndromes corresponding to letter designations) | Consider: |
| Do you/does anyone in your family have chronic low blood cell counts, including low numbers of red blood cells (anemia), low platelet counts, (thrombocytopenia or ITP), low numbers of white blood cells (leukopenia, monocytopenia, lymphopenia)? | A, B, C, F, H, J, K |
| Has anyone required a transfusion for a low blood count? | |
| Did you/does anyone in your family bleed or bruise easily? | A, B, C |
| If yes, have they required transfusions for bleeding? | |
| Do you/does anyone in your family have or have had warts (genital, hands, feet, or any other site)? | F |
| If yes, where and for how many years? | |
| Do you/does anyone in your family get infections easily or severe or unusual types of infections? | F, J, K |
| If yes, how many infections and what type? (e.g., pneumonia, meningitis) and at what age(s)? | |
| Did they require hospitalization or antibiotics? | |
| Does anyone in the family have swelling of one limb larger than the others (also known as lymphedema)? | F |
| If yes, what limb and is there a known reason why that limb is swollen? | |
| Do you/does anyone in your family have deafness? | F, I, J |
| If yes, at what age did it occur and is there a known reason for why that person cannot hear? | |
| Do you/does anyone in your family have abnormal nails (e.g. misshapen or missing not due to injury)? | H, J, K |
| Did you/does anyone in your family get gray hair in their 20s or earlier? Whom and at what age? | H, J |
| Have you or anyone in your family had skin cancer or abnormal coloration of the skin, especially around the neck region? | H, J, K, N |
| Have you/anyone in your family had a specific skin problem called eczema? | C |
| Do you or anyone in your family have lung disease, including pulmonary fibrosis, IPF, or early onset emphysema? | H, J |
| Do you or anyone in your family have a lung disease called pulmonary alveolar proteinosis? | F |
| Do you/does anyone in your family have a liver disease called cirrhosis? | H, J |
| If yes, at what age and is there a known reason why you/they have cirrhosis (for example, heavy alcohol use)? | |
| Have you or other family members had other types of cancer, such as head and neck cancer? | H, J, K, L, M |
| Have you or other family members had other types of cancer, such as cervical or anal cancer? | H, J, K, L |
| Have you or other family members had other types of cancer, such as early onset breast cancer, sarcoma, or brain or colon cancers? | L, M, N |
| Step 3 | |
| Determine exposure history | |
| Do you smoke? If yes, how many packs per day? | |
| Do you drink alcohol? If yes, how many drinks per day? | |
| Have you been exposed to pesticides? If yes, for what career, what agents, and for how many years? | |
| Have you been exposed to radiation and/or chemotherapy? If yes, what drugs or type of radiation were you exposed to and for what reason? | |
| Have you been exposed to other chemicals such as benzene? If yes, what chemicals, why, and for how long? | |
IPF, idiopathic pulmonary fibrosis.