Annapolis Pathology Request Form for Studies of the Mouse Mammary Gland

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Annapolis Pathology Request Form for Studies of the Mouse Mammary Gland

Principal Investigator : Institution:

Tissue Submitted By: Date: / /

Animal Number: Strain: Age: Weeks/Mo)

Experimental: Control: Carcinogen: Virus:

Specify Promotor(s): Specify Transgene(s): Genotype: /

Gender: M F No of Pregnancies: Days of Gestation/Lactation:

Date tumor first noted: / / Date of Sacrifice: / /

Fixative: Days of Fixation:

Processing: Routine (yes/no) ASAP(extra charge): (yes/no) Date: / /

Tissue Collected: (yes/no) Tissue Fixed: (yes/no) Tissue Frozen: (yes/no)

Mammary Gland Sampled: 1. Left Cervical (yes/no) 6. Right Cervical (yes/no)

2. Left Thoracic (yes/no) 7. Right Thoracic (yes/no)

3. Left Thoracic (yes/no) 8. Right Thoracic (yes/no)

4. Left Inguinal (yes/no) 9. Right Abdominal (yes/no)

5. Left Abdominal (yes/no)10.Right Inguinal (yes/no)

Tissues Sampled: A) Soft tissues:

Lung (yes/no) Liver (yes/no)

Brain (yes no) Lymph Nodes (yes/no)

Ovaries/Testis (yes/no) Adrenal glands (yes/no)

Pituitary (yes/no) Kidneys (yes/no)

Thymus (yes/no) Spleen (yes/no)

Other (specify):

Note: Please indicate site of lymph node sampling

B) Skeleton

Vertebrae (yes/no)

Femur (yes/no)

Unsubmitted Tissue Fixed For Future Study (yes/no)

Gross Description and Experimental Protocol

Annapolis Pathology Reporting Form:

Principal Investigator : Institution:

Tissue Submitted By: Date: / /

Animal Number: Strain: Age: Weeks/Mo)

Experimental: Control: Carcinogen: Virus:

Specify Promotor(s): Specify Transgene(s): Genotype: /

Gender: M F No of Pregnancies: Days of Gestation/Lactation:

Fixative: Days of Fixation:

Date Received: / / Date of Processing: / /

Macroscopic Description of Tissue Received:

This should include the details on the request form, together with the pathologist’s description before and after tissue slicing. The size of any tumor or lesion identified should be measured in the maximum diameter in mm. All abnormalities should be described.

Annapolis Pathology Reporting Form

Microscopic Description:

A) BENIGN LESIONS:

Fibroadenoma (yes/no) Adenoma (yes/no)

Adenomyoepithelioma (yes/no)

Nuclear atypia present (yes/no)

Atypia Grade (High – Intermediate - Low)

B) Epithelial Proliferation:

1. Acinar hyperplasia (yes/no)

Physiological Hyperplasia - increase in numbers of acini (yes/no)

GEM-induced Hyperplasia – Alveolar: (yes/no) Ductal: (yes/no)

Focal: (yes/no) Multifocal: (yes/no) Diffuse: (yes/no)

2. Intra-luminal proliferation (yes/no)

Involves ducts: (yes/no) terminal duct lobular units: (yes/no) Unknown: (yes/no)

Epithelial proliferation without atypia: (yes/no)

Epithelial proliferation with atypia: (yes/no) Atypia Grade:(High - Intermediate -Low)

Focal: (yes/no) Multifocal: (yes/no) Diffuse: (yes/no)

Note: Epithelial proliferation with atypia is considered as Mammary Intraepithelial Neoplasia (MIN) by the Annapolis nomenclature

MALIGNANT LESIONS:

Maximum Diameters of Tumor: x (mm)

Tumor Pattern:(circle) Glandular Acinar Cribriform Papillary Solid Squamous

Other (specify):

Invasion:(yes/no) Vascular Invasion: (yes/no) Necrosis: (yes/no) Fibrosis: (yes/no)

Overall Grade: (circle) 1 2 3 not assessable

Mammary lymph nodes: Number positive: Total:

Other node metastases present: (yes/no) Number positive: Total:

Site of other nodes:

D) Metastases:

1. Lung metastases (yes/no) 2. Brain metastases (yes/no)

3. Liver metastases (yes/no) 4. Bone metastases (yes/no)

4. Report on other sites examined:

E) Description of Other Microscopic Findings:

Summary of Findings:

Pathologist: