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Solid Tumor Requisition

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2580 Westside Parkway, Alpharetta, GA 30004
P: 1-800-459-1185 | F: 1-888-809-9071
Date packaged:
Solid Tumor Requisition
CSI_09192021
SINGLE-GENE ASSAYS TUMOR-SPECIFIC PANELS
NEXT-GENERATION SEQUENCING
LABORATORY TESTS REQUIRED (Specimen requirements on back)

 � Consultaon level performed based on specimen and report
materials/informaon provided.
 (specify stains):

 (could include FISH, Cyto, IHC or PCR � see reverse
for complete probe/panel list)
DNA Ploidy DNA Ploidy, p57
 Chromosome Analysis
†
Microarray Analysis
FISH


 


DIAGNOSIS INFORMATION *
Specimen ID:
Slides Stained Unstained Touch Preps
Tissue FNA Body Fluid (specify type):
Paran Block(s): Pick Best Block:
Collecon Date: Time: Date of Discharge:
Body Site:
Formalin Fixed: Yes No Other Fixaon:
Cold Ischemia Time (min): Fixaon Time (min):
†
Signature required for orders of cytogenec tesng that include products of concepon and/or constuonal analysis.
Ordering physician conrms that above paent has been informed and provided consent for tesng.
Original and Second Copy (White / Canary) CSI Laboratories
Boom Copy (Pink) - Client
Last Name: First Name: Middle Inial:
Gender: M F DOB: MRN:
Ordering Physician: Treang Physician:
Age:

Global Tech (Slide Only) Tech (Web) Proles
ER/PR
ER/PR/HER2*
ER/PR/HER2/Ki-67*
ER/PR/HER2/Ki-67/p53*
HER2*
MMRP
PD-L1 SP263 (Imnzi®)
PD-L1 SP142 (Tecentriq®)
PD-L1 22c3 (Keytruda®/Libtayo®)
0 1+ 3+ Reex to HER2 FISH if IHC*
*Global HER2 IHC cases will automacally reex 2+ equivocal results based on 2018 ASCO/CAP HER2 guidelines
Global Tech Global Global
HER2 Bladder Cancer MET (7q31.2)
ALK EGFR (Brain) RET (10q11.21)
ROS1 EWSR1 SS18
FOX01 1p/19q
MDM2
 
PLEASE PROVIDE PATHOLOGY REPORT

IDC-10 Code(s):
Physician Noce: Only tests or diagnosc services that are medically necessary should be ordered. Appropriate ICD-10 informaon must be in the specied area above. Payers, including Medicare and Medicaid, generally do not pay for
screening tests. ABN is required for Medicare paents if ICD-10 codes provided do not support reasoning for tesng.
Prior Cytogenecs / FISH / IHC: Normal Abnormal (Provide Report)
IDH1/IDH2 (GBM)EGFR VIII (Brain)KRAS reex BRAF, NRAS
Lung Panel (PD-L1 (22c3) by IHC; BRAF, EGFR w/T790M; ALK, ROS1 by FISH)KIT (GIST)EGFR w/ T790M (Lung)BRAF
Colorectal Carcinoma Panel (KRAS, NRAS, BRAF; MMRP by IHC global)KIT reex PDGFRA (GIST)EGFR w/T790M; ALK, ROS1 by FISHBRAF reex to MLH1 Methylaon
KIT/BRAF (Melanoma)EGFR w/T790M; reex to ALK, ROS1 by FISHKRAS
Solid Tumor Prole � 434 Genes (DNA)NRASHPV Genotype (LR/HR)MGMT Promoter Methylaon
Solid Tumor PLUS Prole - 1842 Genes (DNA+RNA)MSI by PCR (Normal + Tumor)MLH1 Methylaon
Prior Authorizaon Number:
Bill to: Client Bill Insurance Paent/Self Pay Split Bill: Client (TC) and Insurance (PC)
Bill charges to other hospital/facility:
Account Name & C-Number
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

ABL1 BCL2 CIC EPOR ETV6 FGFR4 GLI1 LY N MYH9 NUP214 PDGFRA PTK2B RUNX1 TCF3
ABL2 BCL6 CREBBP ERG EWSR1 FIP1L1 IKZF3 MAP3K1 NOTCH1 NUP98 PDGFRB RARA RUNX1T1 TFG
AKT3 BRAF CRLF2 ETV1 FGFR1 FLT3 JAK2 MECOM NTRK1 P2RY8 PD-L1 RET SS18 TYK2
ALK CBFB CSF1R ETV4 FGFR2 FOXO1 KMT2A MET NTRK2 PBX1 PICALM RHOA STAT6
BCL1 CBL EGFR ETV5 FGFR3 FUS KRT18P6 MYC NTRK3 PCM1 PML ROS1 TAL1

ABCS3:AE27B7 AURKB C15ORF41 CEBPA DICER1 FANCC FLT3 GRIN2A IRF2 LMO1 MSH2 NTRK1 POLE RANBP2 SETD2 STAT4 TSC2
ABL1 AURKC CALR CHD2 DOT1L FANCD2 FLT4 GRM3 IRF4 LPIN2 MSH6 NTRK2 POT1 RARA SF3B1 STAT6 TSHR
ABL2 AXIN1 CARD11 CHD4 EED FANCE FOXL2 GSK3B IRS2 LRP1B MTOR NTRK3 PPM1D RB1 SLIT2 STK11 U2AF1
ACD AXIN2 CBFB CHEK1 EGFR FANCF FOXP1 GSKIP JAGN1 LYN MUTYH NUP93 PPP2R1A RBBP6 SLX4 SUFU U2AF2
ACVR1B AXL CBL CHEK2 EGLN1 FANCG FRS2 H3F3A JAK1 LYST MVK PAK3 PRDM1 RBM10 SMAD2 SUZ12 VEGFA
ADA B2M CBLB CIC ELANE FANCI FUBP1 HAX1 JAK2 LZTR1 MYC PALB2 PREX2 RBM8A SMAD3 SYK VHL
AK2 BAP1 CBLC CREBBP EP300 FANCL G6PC3 HGF JAK3 MAGI2 MYCL PARK2 PRKAR1A RET SMAD4 TAF1 WAS
AKT1 BARD1 CCND1 CRKL EPAS1 FANCM GABRA6 HIST1H3B JUN MAP2K1 MYCN PAX5 PRKCI RHEB SMAD9 TAL1 WHSC1
AKT2 BCL2 CCND2 CRLF2 EPCAM FAS GALNT12 HNF1A KAT6A MAP2K2 MYD88 PBRM1 PRKDC RHOA SMAD9L TBX3 WISP3
AKT3 BCL2L1 CCND3 CSF1R EPHA3 FAT1 GATA1 HOXA11 KDM5A MAP2K4 NBN PDCD1LG2 PRSS1 RICTOR SMARCA4 TCF3 WT1
ALK BCL2L2 CCNE1 CSF3R EPHA5 FBXW7 GATA2 HOXB13 KDM5C MAP3K1 NF1 PDGFRA PRSS8 RIT1 SMARCB1 TCIRG1 XPO1
AMER1 BCL6 CD274 CTC1 EPHA7 FGF10 GATA3 HRAS KDM6A MAP3K14 NF2 PDGFRB PSTPIP1 RNF168 SMC1A TERC XRCC2
ANKRD26 BCOR CD79A CTCF EPHB1 FGF14 GATA4 HSD3B1 KDR MAPK1 NFE2L2 PDK1 PTCH1 RNF43 SMC3 TERF1 XRCC3
APC BCORL1 CD79B CTNNA1 ERBB2 FGF19 GATA6 HSP90AA1 KEAP1 MCL1 NFKBIA PHF6 PTEN ROS1 SMO TERF2 ZBTB2
AR BCR CDAN1 CTNNB1 ERBB3 FGF23 GEN1 ID3 KEL MDM2 NHP2 PIK3C2B PTPN11 RPTOR SNCAIP TERF2IP ZNF217
ARAF BIRC3 CDC73 CUL3 ERBB4 FGF3 GFI1 IDH1 KIF23 MDM4 NKX2-1 PIK3CA QKI RTEL1 SOCS1 TERT ZNF703
ARFRP1 BLM CDH1 CUX1 ERCC4 FGF4 GFI1B IDH2 KIT MED12 NLRP3 PIK3CB RAB27A RUNX1 SOX10 TET2 ZRSR2
ARID1A BMPR1A CDK12 CXCR4 ERG FGF6 GID4 IGF1R KLF1 MEF2B NME1 PIK3CG RAC1 RUNX1T1 SOX2 TGFBR2
ARID1B BRAF CDK4 CYLD ERRFI1 FGFR1 GLI1 IGF2 KLHL6 MEFV NOP10 PIK3R1 RAD21 SBDS SOX9 TNFAIP3
ARID2 BRCA1 CDK6 DAXX ESR1 FGFR2 GLI2 IKBKE KLLN MEN1 NOTCH1 PIK3R2 RAD50 SBF2 SPEN TNFRSF14
ASXL1 BRCA2 CDK8 DDR2 ETV6 FGFR3 GNA11 IKZF1 KMT2A Merged NOTCH2 PIM1 RAD51 SDHA SPOP TNFRSF1A
ATG2B BRD4 CDKN1A DDX11 EXO1 FGFR4 GNA13 IKZF3 KMT2B MET NOTCH3 PLCG1 RAD51B SDHB SPTA1 TOP1
ATM BRIP1 CDKN1B DDX41 EZH2 FH GNAQ IL2RG KMT2C MITF NPM1 PLCG2 RAD51C SDHC SRC TOP2A
ATR BTG1 CDKN2A DKC1 FAM175A FLCN GNAS IL7R KMT2D MLH1 NRAS PMS1 RAD51D SDHD SRSF2 TP53
ATRX BTK CDKN2B DNM2 FAM46C FLI1 GPR124 INHBA KRAS MPL NROB1 PMS2 RAD54L SEC23B STAG2 TRAF3
AURKA C11orf30 CDKN2C DNMT3A FANCA FLT1 GREM1 INPP4B LIG4 MRE11A NSD1 POLD1 RAF1 SETBP1 STAT3 TSC1
 
Cytogenecs Fresh Tissue Mulple 2-3 mm pieces of ssue in RPMI transport media (opmum RPMI to ssue rao is 15:1; mulple vials are acceptable).
FISH*
Fresh Tissue Mulple 2-3 mm pieces of ssue in RPMI transport media (opmum RPMI to ssue rao is 15:1; mulple vials are acceptable).
Voided Urine or Bladder Wash
(Bladder Cancer FISH)
Minimum of 33 mL voided urine or bladder washing mixed 2:1 with preservave (Preservcyt
©
or Carbowax™). Sample should be stored in refrigerator
(4°C) unl it is packaged for transport and sent for processing within 24 hours of collecon. Sample should be shipped with ice packs. Urine samples
should not be shipped or stored at temperatures above 25°C and should be processed within 48 hours of collecon.
Formalin-Fixed Paran-Embedded Tissue Minimum 0.2 x 0.2 x 0.2 cm ssue; non-decalcied ssue only (FISH only).
Molecular
Fresh Tissue Minimum of 250 mg ssue in RPMI transport media.
Formalin-Fixed Paran-Embedded Tissue
1 H&E slide and 6-8 unstained slides, 5-7 microns of ssue xed with 10% NBF xave. Please circle tumor for microdissecon. Alternavely, the FFPE
block of the BM clot can be sent for seconing in our lab.
IHC 1 H&E slide with its corresponding paran block (10% neutral buered formalin) - Preferred.
*For tech-only services, include 1 marked H&E slide (all at 4 microns). MUST CIRCLE AREA OF INTEREST ON H&E SLIDE.
CSI_09192021
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Solid Tumor Requisition

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Completed 18 June 2022

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