Cancer Cytogenetics & Molecular Diagnostics Laboratory
University Health Network/Department of Pathology
Toronto General Hospital
Eaton Wing 11-444, 200 Elizabeth Street
Toronto, Ontario M5G 2C4
Phone: (416) 340-4800 x5739/7624
Fax: (416) 340-3596
Hours of Operation (Mon-Fri) 8:30AM-4:30PM
Director: Suzanne Kamel-Reid, PhD FACMG
Associate Director: Tracy Stockley, PhD, FCCMG
Molecular Geneticist: Cuihong Wei, PhD, FCCMG
CAP#: 7175217 CLIA#:99D1106115
Patient Information or Hospital Stamp Here
Last Name:
First Name:
Date of Birth (DD/MM/YYYY):
Gender:
Health Card #:
Hospital #:
Instructions:
1.Complete all information as requested
2.Send requisition with specimen to address above
3.Keep specimen at room temperature unless frozen
4.If shipping, send same day or next day delivery
5.Specimen labelling: Name, DOB, MRN#
Information for Reporting
Full Name of ordering physician:
Hospital/Address:
Phone:
Fax:
Clinical Diagnosis/
History (if required):_________________________________
Current Status of Patient:
‰ First sample at diagnosis
‰ Follow-up
‰ Chemo (specify type) _______ (wks/mos/yrs)___________
Clinical Indication:
‰ Carrier testing
‰ Family history? Yes____ No_____
‰ Relationship to proband:
‰ Family mutation if known:
Sample Information:
Molecular Diagnostics
‰ Peripheral blood
20 cc in EDTA for leukemia/lymphoma
10 cc in EDTA for all others
‰ Bone marrow from a relocated needle
1-2 cc in EDTA
‰ Tissue/cell block (BLOCK IS PREFERRED)
o copy of the pathology report is required
oCorresponding H&E slide is required
oBLOCK: Note that punch biopsies will be taken from the block
oUnstained slides (only if BLOCK is not available)
¾Cut 12 unstained sections @ 7µm thickness on uncoated
slides
¾Air-dry unstained sections at room temperature. Do not dry
in oven.
¾For all tissues we require 2 H&E stained sections, One cut
before cutting sections and one cut after. Circle the tumour
on the H&E stained slides.
¾Orient all unstained and stained sections in the same way
¾Store all slides at room temperature and send within 5-7
days of cutting
oPE tissue (curls) 10x10µm sections in sterile eppendorf tube
oFresh tissue/lymp node: 5mm3 frozen or in 10 ml sterile medium
at room temperature
‰ CSF: As much as possible
‰ FNA: As much as possible
Cytogenetics
‰ Bone marrow aspirate from a relocated needle (1.5-2 cc in sodium
heparin)
‰ Peripheral blood (7 cc in sodium heparin)
‰ Tissue biopsy (5-10mm3 in sterile medium/saline)
‰ Paraffin Embedded Tissue (FISH) (incl. circled H&E)
2 x 4µm sections per probe on positively charged slides
‰ Cytology preparation (FISH)
Air-dried smear/touch prep (1-2 per test)
Cytospin slide (1-2 per test)
Collection date/time:
Collected by:
Lab consultation needed for any alternate specimen type
Please ensure that you are using an updated copy of this requisition available at:
http://www.uhn.ca/LMP/Health_Professionals/Documents/Cytogenetics%20and%20Molecular%20Diagnostics%20tests.pdf
Version 3.0 March 2015
Page 1/2
Cancer Cytogenetics & Molecular Diagnostics Laboratory
University Health Network/Department of Pathology
Toronto General Hospital
Eaton Wing 11-444, 200 Elizabeth Street
Toronto, Ontario M5G 2C4
Phone: (416) 340-4800 x5739/7624
Fax: (416) 340-3596
Hours of Operation (Mon-Fri) 8:30AM-4:30PM
Director: Suzanne Kamel-Reid, PhD FACMG
Associate Director: Tracy Stockley, PhD, FCCMG
Molecular Geneticist: Cuihong Wei, PhD, FCCMG
CAP#: 7175217 CLIA#:99D1106115
Patient Information or Hospital Stamp Here
Last Name:
First Name:
Date of Birth (DD/MM/YYYY):
Gender:
Health Card #:
Hospital #:
Cytogenetics Test(s) Requested
Molecular Diagnostics Test(s) Requested (continued)
A Pathology / Hematology report must be sent. Tests will be
delayed until this information is received.
Lymphoma
‰B-cell clonality
‰T-cell clonality
‰
‰
Karyotype
FISH
‰
CLL Panel
‰
Multiple Myeloma panel
Lymphoma:
‰
Diffuse aggressive B cell NHL:
(Specify: MYC, IGH/BCL2, BCL6)
‰
Anaplastic large cell lymphoma: ALK
‰
MALT lymphoma: MALT1, Trisomy 3,
Trisomy 18
‰
Mantle cell lymphoma: IGH/CCND1
‰
Follicular lymphoma: IGH/BCL2
Solid Tumour:
‰
Breast cancer: HER2
‰
Gliomas: 1p/19q
‰
Lung cancer : ALK (need additional u/s slide
for IHC)
‰
Sarcoma: (Specify) EWSR1, FUS, SYT
‰
Melanoma
Molecular Diagnostics Test(s) Requested
Hereditary Disorders
‰
Thrombosis
‰
Factor V (Leiden) / FII (G20210A)
‰
MTHFR C677T (if homocysteine is elevated)
‰
‰
Hemochromatosis (HFE Cys282Tyr and His63Asp)
Malignant hyperthermia: RYR1 (Patient must be
referred to MH clinic prior to molecular testing)
‰
Hereditary amyloidosis: TTR, FGA, LYZ, APOA1
Identity Test (15 STRs and amelogenin XY loci)
‰
BMT monitoring
‰
Specimen Matching (Please provide details)
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Solid Tumours (Note: Please send requisitions to specimen holding
facility to ensure that block/slides accompany requisitions when sent to
testing lab)
Type:
‰ GIST
‰ Papillary thyroid
‰ Melanoma
carcinoma
‰ Glioma
‰ Colorectal carcinoma
‰ Endometrial
‰ Adenocarcinoma of
Carcinoma
the Lung
‰ Other_____________
Markers:
‰
‰
‰
‰
‰
EGFR
BRAF
NRAS
KIT
PDGFR
‰
‰
‰
KRAS
MSI
MGMT
methylation
Virus detection
‰Quantitative EBV
‰HPV Genotyping
Leukemia
Type:
‰ALL
‰CML
‰MLL
‰AML (specify type______________)
‰Other
Test:
‰BCR/ABL1 t(9;22)
‰ABL1 kinase domain mutation
‰MLL/AF4 t(4;11)
‰AML1/ETO t(8;21)
‰CBFβ/MYH11 Inv(16) or t(16;16)
‰KIT (if positive for t(8:21) or inv (16))
‰PML/RARA t(15;17)
‰*FLT3 (ITD & D835 mutations)/*NPM1
*Only done on samples with a normal karyotype, please
include a cytogenetics report if done elsewhere
Other
‰ Mastocytosis: KIT (BM or involved tissue preferred)
‰ Hypereosinophilic syndrome, CEL: FIP1L1/PDGFRA
‰ BRAF (HCL, Langerhans cell histiocytosis, Erdheim-Chester)
‰ JAK2 V617F (Specify PV____ ET_______ or MF______)
‰ CALR (Suspected ET___ or MF___ only) Note: Only done on
JAK2 neg samples, please include report if done elsewhere