Oncology Request Form
Hennepin Healthcare
Cytogenetics Laboratory
701 Park Avenue, Mpls., MN 55415
Please call the laboratory when sending a specimen: phone: 612-873-8548 pager: 612-268-6234.
Patient Name
Date of birth
Sex
Male
Female
Client medical record number
Referring physician(s)
Collection date
Collection time
AM or PM
AM
PM
Institution
Bill to:
Account
Patient*
(*Please attach billing information.)
DIAGNOSIS:
Chromosome Study:
Run
Run STAT
Process & Hold
Bone marrow
Hematologic blood
Malignant tissue
FISH Study:
Run
Run STAT
Process & Hold
Bone marrow
Hematologic Blood
Smear/touch prep
source:
Block
source:
Other
source:
Lymphoid FISH Disorders:
Acute lymphoblastic leukemia:
ALL panel:
t(1;19), 4/10/17, 7p12, t(9;22), 11q23.3, t(12;21), iAMP21
ALL panel,Philadelphia-like:
1q, 5q, 9p, 9q, Xp22
t(1;19)( TCF3-PBX1 (E2A)
Hyerdiploidy 4/10/17
7p12 IKZF1 (IKAROS)
t(9;22) BCR/ABL1
11q23.3 KMT2A (MLL)
t(12;21) ETV6/RUNX1
1q25 ABL2
5q PDGFRB
9p JAK2
9q34 ABL1
Xp22 CRLF2
11q23.3 KMT2A (MLL)
t(12;21) ETV6/RUNX1
Small B-cell leukemia/lymphomas:
CLL panel:
11q, 12cen, 13q, 17p
CLL & CCND1 panel:
11q, 12cen, 13q, 17p, t(11;14)
CLL limited panel:
11q, 17p
Mantle cell: t(11;14) CCND1/IGH
Marginal zone lymphoma MALT panel:
3q (BCL6), 7q, 18q(MALT1), t(11;18) BIRC3/MALT1, t(14;18) IGH/MALT1
Nodal marginal zone lymphoma panel:
3q (BCL6), 7q, 18q(MALT1)
Splenic marginal zone lymphoma panel:
3q (BCL6), 7q
Follicular/Large B-cell/High-grade lymphomas:
Dual hit lymphoma panel:
BCL6, MYC, MYC-IGH, IGH/BCL2
Dual hit lymphoma cascade panel:
do MYC & MYC-IGH first. If abnormal, reflex BCL6 and IGH/BCL2
3q27 BCL6 DLBCL
6p25.3 IRF4 LBCL
8q24.21 MYC Burkitt
t(8;14) MYC/IGH Burkitt
11q abnormality (MGR,MLR) Burkitt-like
t(14;18) IGH/BCL2 Follicular
Plasma cell myeloma:
Myeloma panel:
1pq, t(4;14), t(11;14), 13q, t(14;16), t(14;20), 17p
Myeloma limited panel:
t(4;14), t(14;16), 17p
T-cell lymphomas:
2p23 ALK Anaplastic Large Cell
TRA (14q11.2)
TCL1A, TCL1B (14q32.1)
Myeloid FISH Disorders
Myeloproliferative neoplasm:
CML: t(9;22) ABL1/BCR
Myelodysplastic syndrome:
MDS panel:
5q, 7q, +8, 20q
5q, -5
7q, -7
+8
20q
17p (TP53)
Eosinophilia:
Eosinophilia panel:
4q, 5q, 8p, 9p
Eosinophilia panel:
4q, 5q, 8p, 9p, 9q, 13q
4q FIP1L1, PDGFRA
5q PDGFRB
8p FGFR1
9p JAK2
9q ABL1
13q FLT3
Acute myeloid leukemia:
AML panel:
inv(3), t(8;21), 11q, t(15;17), inv(16)
inv(3), t(3;3) MECOM
t(8;21) RUNX1T1/RUNX1
11q23.3 KMT2A (MLL)
t(15;17) PML/RARA
inv(16) MYH11,CBFB
Solid tumors:
t(11;22) EWSR1 Ewing Sarcoma
1, 19 deletions Oligodendroglioma
t(X;18) SYT Synovial Sarcoma
Breast cancer (paraffin embedded):
ERBB2 (HER2) FISH
Specimen origin:
Block Number:
Histologic type:
Cold ischemia time:
Time in formalin:
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