Cell Line/Xenograft Information Submission Form
1. Type of submission:
Cell line
Xenograft
Name of Cell line/Xenograft:
ATCC number (if available):
Name
Institution
Mailing Address
City
State
Zip
Telephone
Fax
(if international, please include the country code for the telephone and fax)
E-mail address(es)
A. Patient’s Age at Diagnosis
(years)
B. Gender:
Female
Male
C. Race (check all that apply):
African American or Black
White
American Indian or Alaska Native
Unknown
Asian
Other (specify):
Native Hawaiian or other Pacific Islander
D. Ethnicity (check only one):
Hispanic or Latino(a)
Non-Hispanic or Latino(a)
E. Is the tumor from someone with a known genetic syndrome?
No
Yes
(if yes, please indicate which genetic syndrome):
A. Diagnosis:
Acute Lymphoblastic Leukemia (ALL)
Non-Hodgkin’s Lymphoma (NHL)
Acute Myeloid Leukemia (AML)
Osteosarcoma
Ependymoma
Rhabdoid tumor ( indicate region):
Hepatoblastoma
Ewing’s Family of Tumors (PNET)
Rhabdomyosarcoma (Embryonal)
Medulloblastoma
Rhabdomyosarcoma (Alveolar)
Neuroblastoma
Wilm’s tumor
Glioma NOS
Other (please indicate):
B. Tumor Stage at initial diagnosis:
Localized
Regional
Metastatic
C. Tumor Status (at the time of cell line/xenograft establishment):
Newly diagnosed
Recurrent
D. Prior Treatment (check all that apply):
No prior treatment
Prior chemotherapy
Prior XRT
E. Tumor cells obtained from:
Primary site
Metastatic site
F. Description of anatomic site of primary tumor (be as specific as possible):
G. Description of anatomic site from which tumor cells obtained (be as specific as possible):
H. If you did not isolate this cell line/xenograft, indicate from whom you received it (the arrows will indicate the succession of individuals and/or institutions who maintained this specific strain).
POPP-TAP ß Provider ß
ß
I. Was an IRB consent form obtained for establishing the cell line or xenograft?
Not applicable
Please provide any additional information regarding the IRB for this study:
A. Passage number on receipt (if obtained from another laboratory):
B. Method of establishment:
Culture
Passage through xenograft
Viral transformation
C. Culture media, sera, and other culture supplements:
D. Doubling time:
(hours)
E. Split frequency:
(days)
F. Current number of passages:
G. Has crisis occurred?
Yes (please indicate which passage number):
H. Do cells grow in soft agar?
I. Do cells form tumors in mice?
Yes (if yes, please indicate which strain):
J. Date of most recent mycoplasma test (MM/DD/YY):
K. Cell Line cryopreservation conditions:
% DMSO:
% Serum:
Other additives (please indicate with %):
A. Method of establishment:
Cell culture in vitro prior to xenograft establishment?
(if selected, complete “Cell line characteristics” above as well)
Direct transplantation
B. Number of cells injected to produce tumor, if relevant:
C. Orthotopic transplant?
Yes (if yes, specify location):
D. Mouse strain maintained in:
E. Doubling time:
F. Current method of maintenance:
G. Current number of passages:
H. Metastatic potential:
Yes (if yes, describe metastatic sites):
I. Earliest passage cryopreserved:
K. Xenograft cryopreservation conditions:
A. Has conventional cytogenetics been done?
Yes (if yes, please summarize results or if possible submit the karyotype report):
B. Has a spectral karyotype been done?
Yes (if yes, please summarize results or if possible submit the spectral karyotype report):
C. Are you submitting a conventional and/or spectral karyotype separately?
Yes (if yes, the karyotype may be submitted separately as an e-mail attachment or by postal or courier service – see addresses below. Be sure to include your full name, the cell line or xenograft name, the type of karyotype being submitted, and a description of any software needed to view an electronic file)
D. Has conventional (i.e. metaphase) comparative genomic hybridization been done?
Yes (if yes, please summarize results):
A. Has any molecular screening of the cell line/xenograft been done?
Yes (if yes, please complete the following molecular information)
B. Were inactivating mutations or deletions of tumor suppressor genes identified (e.g., p53, PTEN, p14 (ARF), p16 (INK4A), p19, Rb, etc.)? If yes, specify gene and mechanism of inactivation:
C. Were activating mutations of oncogenes identified (e.g., ras)? If yes, specify gene and the activating mutation if known:
D. Have amplified genes or chromosome loss/gain regions been identified?
Not evaluated
Yes (if yes, please list chromosomal regions and genes that are amplified):
For the specific types of cancers listed below, please complete the following if applicable for each cell line/xenograft:
E. Acute lymphoblastic leukemia (ALL), Immunophenotype:
Mature B-cell
B-precursor
T-cell ALL
F. Acute lymphoblastic leukemia (ALL), Surface antigens (check all that apply):
CD2
CD19
Other (please specify):
CD7
CD20
CD3
CD22
CD10
CD34
G. Acute lymphoblastic leukemia (ALL), recurring molecular abnormalities:
MLL gene rearrangement
Myc gene rearrangement
TEL-AML1 (ETV6-CBFA2)
Bcr-Abl
E2A-PBX1
H. Acute myeloid leukemia (AML) FAB subtype:
M0
M3
M6
M1
M4
M7
M2
M5
