Oxford Molecular Genetics Laboratory Request for Tumour Profiling
(Microsatellite Instability (MSI) analysis)
NB. THIS IS A CLINICAL REQUEST REQUIRED FOR PATIENT / FAMILY
MANAGEMENT.
Please complete the following form and send with the tumour tissue to the Oxford
Molecular Genetics Laboratory at the address below.
Patient Details (to be completed by referring clinician)
Surname:
Forename:
Address:
Date of Birth:
Sex: F/M
NHS Number:
Hospital Number:
Case Number:
HNPCC family number (if known):
Tumour Details (to be completed by histopathology)
Sample type: Formalin fixed paraffin embedded (FFPE) tumour block / slide mounted
sections / other (if other please specify)
(Please note, accurate MSI analysis relies on sampling tumour tissue.
For FFPE tumour analysis, 5 x 6-8µM sections are required mounted on microscope slides,
with one additional representative section H and E stained with the tumour boundary
marked)
Block number/slide ref:
Tumour histology:
Date of biopsy:
Estimated Percentage Tumour in sample:
%
Referring Clinician (signature)…………………………………………
Referring Clinician (please print)……………………………………..
Referring Clinician Contact Details……………………………………………………………...
Date of Request…………………… Referral Centre…………………………………
Please send the tumour sample as soon as possible to:
Oxford Molecular Genetics Laboratory,
Churchill Hospital,
Old Road, Oxford.
OX3 7LJ.
Tel 01865 225594.
Email: DutyScientist.DnaLab@orh.nhs.uk
http://www.oxfordradcliffe.nhs.uk/geneticslab