MACROSCOPIC (check all that apply)
SPECIMEN TYPE
___ Cytology
___ Biopsy
TUMOR SITE
___ Right eye
___ Left eye
___ Unknown
PART OF THE EYE SAMPLED
___ Anterior chamber
___ Vitreous
___ Choroid
___ Ciliary body
___ Iris
___ Other
(specify:_____________________)
FIXATION
___ Alcohol
___ NBF
___ Other
___ None
QUANTITY
___ Amount of fluid
___ Specimen Size: ___ x ___ x ___
mm
___ Other
(specify:_____________________)
TUMOR SIZE (largest dimension), if appropriate:
___ mm
MICROSCOPIC (check all that apply)
ADEQUACY OF SPECIMEN FOR ANALYSIS
___ Adequate
___ Inadequate, specify reason:
_____________
PART OF UVEA INVOLVED
___ Choroid
___ Ciliary body
___ Iris
HISTOLOGIC
TYPE
___ Cannot be determined
___ Spindle cell type
___ Spindle A
___ Spindle B
___ Epithelioid cell type
___ Mixed
cell type
___
Necrotic
___ Balloon
cell
INVOLVEMENT OF OTHER STRUCTURES
___ Cannot be determined
___ Sclera
___ Vortex vein
___ Optic Nerve
___ Vitreous
___ Retina
___ Angle/Schlemm’s canal
___ Other(s)
(specify:_____________________)
ADDITIONAL PATHOLOGIC FINDINGS
___ None identified
___ Mitotic rate: Number of mitoses
per 40x objective with a field area of 0.152 mm2 ______
___ Necrosis
___ Microvascular patterns
___ Vascular invasion (tumor vessels
or other vessels)
___ Degree of pigmentation
___ Inflammatory cells/tumor
infiltrating lymphocytes
___ Drusen
___ Nevus
___ Hemorrhage
___ Neovascularization
___ Changes associated with previous
therapy
___ Other (specify:
_____________________)
COMMENT
___________________________________________
___________________________________________
___________________________________________
___________________________________________