MF105-MolForm V3-04-02-2014
Molecular Pathology Request Form
Please send requests
to
Dr Shu An
Division of Neuropathology, UCL Institute of Neurology
Queen Square.
London WC1N 3BG
email: s.an@ucl.ac.uk
Web address for further
information
http://www.ucl.ac.uk/ion/divisions/neuropathology/diagnostic_servi
ces/molecular_tests
For Laboratory use only
Test requested
LOH 1p/19q;
LOH10q, EGFR Amp
IDH mutation
Date of arrival
Recommended for
All low and high grade
Oligodendroglial and astrocytic
tumours;
To differentiate AO from GBM
LGG where IHC is negative
GBM, clinical trials
Pilocytic astrocytoma
IDH sequencing only
EGFRvIII
BRAF Fusion&
BRAF V600E
BRAF V600E only
MGMT Promoter
methylation
Not sure:
Patient details
Name
Surname
Date of birth
Address
NHS Number
Referred diagnosis
Referred material
Referral Pathology ID (Block
number)
£75
£250
£320
Sequencing
RT-qPCR
RT-qPCR, sequencing
Ganglioglioma, SEGA, Melanoma
£65
Sequencing
High grade glioma, mainly GBM
£195
HRM PCR
(Temozolamide treatment),
Leave decision to molecular pathology department. Note: multiple tests cost
less than the sum of the single components. See website for details
M
Block
8-10 slides (10µm)
Details of the referring hospital and clinician
Hospital
Address
Postcode
Consultant name
Consultant email
(Report will be sent to this
email)
Address to return material
Print Print Form
NH number
Cost
Test method
£255
qPCR, sequencing
Email Form
F