PCMP Test Requisition Form & Specimen Requirements

Division of Molecular Anatomic Pathology
PERSONALIZED CANCER MUTATION PANEL (PCMP)
Targeted Mutation Detection by Next Generation Sequencing
SHIP TO: Univ. of Pittsburgh Medical Center
Dept. of Pathology
Molecular Anatomic Pathology Laboratory
Room S-752 Scaife Hall
200 Lothrop Street
Pittsburgh, PA 15213
Phone: 412-648-9451
FAX: 412-802-6799
Date:
PHS#
(To be completed by MAP Lab Staff)
PATIENT INFORMATION/CLINICAL INFORMATION/ REPORTING INFORMATION
NAME: __________________________ _______________ ___ DATE OF BIRTH: ___ / ___ / ___ GENDER: M F
LAST NAME FIRST NAME MI
SURGICAL PATHOLOGY/ CYTOLOGY REPORT #:
INSTITUTION NAME:
REQUESTING PHYSICIAN NAME:
REQUESTING PHYSICIAN ADDRESS: PHONE #
SS#
FAX #
DIAGNOSIS:_____________________________________________________ ___ Surgical Pathology/Cytology report must be included
PERSON/INSTITUTION RESPONSIBLE FOR PAYMENT:
BILLING INFORMATION:
BILLING ADDRESS:
PHONE #______________________________________
FAX #_________________________________________
MAP LAB TEST NAME: TEST DESCRIPTION* CLINICAL INDICATION FOR TEST**
PERSONALIZED CANCER
MUTATION PANEL (PCMP)
Targeted Mutation Detection by Next Generation
Sequencing in 739 hot spots of 46 genes (ABL1, AKT1,
ALK, APC,ATM, BRAF, CDH1, CDKN2A, CSF1R, CTNNB1,
EGFR,ERBB2, ERBB4, FBXW7, FGFR1, FGFR2, FGFR3,
FLT3,GNAS, HNF1A, HRAS, IDH1, JAK2, JAK3, KDR,KIT,
MET, MLH1, MPL, NOTCH1, NPM1, NRAS, PDGFRA,
PIK3CA, PTEN, PTPN11, RB1, RET, SMAD4, SMARCB1,
SMO,SRC, STK11, TP53, and VHL)*
BREAST CANCER
COLORECTAL CANCER
LUNG CANCER
OVARIAN CANCER
BRAIN CANCER
RENAL CANCER
MALIGNANT MELANOMA
OTHER (PLEASE SPECIFY)_________________
*THE FULL LIST OF MUTATIONS TARGETED IN THIS PANEL CAN BE FOUND ON OUR WEBSITE AT: www.path.upmc/divisions/map
**SURGICAL PATHOLOGY REPORT MUST BE ATTACHED
Page 1 of 2 Last updated: 10/30/12

Division of Molecular Anatomic Pathology
PERSONALIZED CANCER MUTATION PANEL (PCMP)
Targeted Mutation Detection by Next Generation Sequencing
SHIP TO: Univ. of Pittsburgh Medical Center
Dept. of Pathology
Molecular Anatomic Pathology Laboratory
Room S-752 Scaife Hall
200 Lothrop Street
Pittsburgh, PA 15213
Phone: 412-648-9451
FAX: 412-802-6799
TECHNICAL INFORMATION:
Methodology: Multiplex PCR followed by Next Generation Sequencing
Specimen Type:
Requirements:
FFPE – Unstained Slide(s)
6 unstained 5um FFPE slides containing adequate amounts of tumor to be analyzed with areas of tumor marked.
Please include a copy of corresponding surgical pathology report.
Transport Temperature: sent at 20-25˚C. Protect paraffin tissue from excessive heat. Ship in cooled container
during summer months.
Unacceptable conditions: No tumor in tissue, decalcified specimen, alternative fixtures.
Shipping Conditions:
Specimen Type:
Requirements:
Ship at room temperature (20-25˚C) in an insulated container by overnight courier. Do not heat or freeze.
FFPE – Tumor Block
Paraffin-embedded, formalin-fixed tissue block containing adequate amounts of tumor to be analyzed with areas
tumor marked. Please include a copy of corresponding surgical pathology report.
Transport Temperature: sent at 20-25˚C. Protect paraffin tissue from excessive heat. Ship in cooled container
during summer months.
Unacceptable Conditions: No tumor in tissue, decalcified specimen, alternative fixtures.
Shipping Conditions:
Specimen Type:
Requirements:
Shipping Conditions:
Specimen Type:
Requirements:
Shipping Conditions:
Turn Around Time:
Ship at room temperature (20-25˚C) in an insulated container by overnight courier. Do not heat or freeze.
Fresh Frozen Tissue
50-150 mg (0.5-1.0 cm3) Fresh tissue snap frozen at -20˚C. Store at -20˚C. Tissue specimen containing at least
50% of tumor cells can be either placed into cryogenic tube and snap frozen in liquid nitrogen, or placed into a
tube with preservative solution provided by the Molecular Anatomic Pathology laboratory (request solution from
the lab) and frozen at -20ºC.
Ship on dry ice in an insulated container by overnight courier.
Other
Please contact the laboratory to discuss other specimen types that may be acceptable.
Please contact the laboratory to discuss if shipping other specimen types.
7 – 14 days
Page 1 of 2 Last updated: 10/30/12