Select analysis on the next pages. Sample request and sending address see last page. Institut für Pathologie und Molekularpathologie
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1 Diagnostic Tumor Genome Analysis Schmelzbergstrasse Zürich Tel.: (+41) Fax.: (+41) Client (address, telephone number): Sample-Nr: Sent in: Paraffin block Frozen tissue EDTA-Blood Cyto. Smear Plasma DNA Patient male female Surname: Name: Date of birth: Address: Diagnosis: Specific questions: Invoice to: Client Patient other: Date: Signature: Sender (if not client): Report copy to: General Informed Consent from USZ filled out and attached: Select analysis on the next pages Sample request and sending address see last page 7FO-Einsendeformular_SP_englisch_ PTK.docx Seite 1 von 5
2 Lung EGFR KRAS (incl. EGFR, KRAS, ALK Mutations; ALK, ROS1, RET Translocations, MET Exon 14 skipping, MET und ERBB2 Amplifications) Lung cfdna Assay (incl. EGFR, KRAS) ALK ROS1 PD-L1 c-met HER2 GI-Tract KRAS (incl. KRAS, BRAF, NRAS, KIT, PDGFRA Mutations; PDGFRA, KIT Amplifications) (incl. KRAS, BRAF, NRAS) MSH2, MSH6, PMS, MLH1 BRAF VE1 (IHC, p.v600e spezifisch) Skin (incl. BRAF, NRAS, KIT, GNAQ, GNA11 Mutations) (incl. BRAF, NRAS) BRAF VE1 (IHC, p.v600e spezifisch) Brain (incl. AKT1, BRAF, IDH1, IDH2, EGFR variant III Mutations, KIAA1549:BRAF Fusions) (incl. AKT1, BRAF) 7FO-Einsendeformular_SP_englisch_ PTK.docx Seite 2 von 5
3 Soft tissue / Bone (incl. CTNNB1 Mutations) Archer Sarcoma (incl. t(11;22), t(x;18), t(12;16), t(12;22), t(21;22), t(7;16), t(11;16), t(1;13), t(2;13)) (incl. CTNNB1, GNAS) Ovary / Breast / Prostate / Pancreas Oncomine BRCA (incl. all coding exons; BRCA1+2 Deletions; LargeINDELS, Duplications) (incl. ERBB2 Mutations and Amplifications) Breast cfdna Assay (incl. ERBB2) HER2 Progesteronrezeptor Östrogenrezeptor Hematopathology TP53 (incl. all coding exons) TrueSight Myeloid (incl. BRAF, MYD88) (incl. BRAF, MAP2K1) (incl. BRAF, MAP2K1) 7FO-Einsendeformular_SP_englisch_ PTK.docx Seite 3 von 5
4 Single / sequential mutation analyses Order form Diagnostische Molekularpathologie Tel.: (+41) FISH-Analyses Order form ISH; Labor für In situ-techniken Tel.: (+41) Prognostic Order form Laboratory of Molecular Tel.: (+41) FO-Einsendeformular_SP_englisch_ PTK.docx Seite 4 von 5
5 Probe requests for the different analyses and price Please send material for analyses together with the order form to: UniversitätsSpital Zürich Institut für Pathologie und Molekularpathologie Histologielabor PATH F 1 z.hd. Diagnostische Tumor-Genomanalyse Schmelzbergstrasse Zürich / Schweiz Analysis from fixed tissue possible; if possible add an actual HE staining (TARMED-Pos. 1x : TP) KRAS (TARMED-Pos. 1x : TP) EGFR (TARMED-Pos. 1x : TP) Analysis from fixed and frozen tissue, cytological smears and DNA/RNA possible Oncomine TM BRCA Research Assay (TARMED-Pos. 4x : TP) (DNA, RNA) (TARMED-Pos. 5x : 2'353 TP) Analysis from fixed and frozen tissue, DNA and EDTA-Blood possible Ion AmpliSeq TP53 (TARMED-Pos. 2x : TP) Analysis from fixed, frozen tissue and RNA possible Archer Sarcoma (TARMED-Pos. 3x : 1' TP) Analysis from EDTA-Blood, EDTA-bone marrow aspirate or biopsy in NaCl and DNA possible TruSight Myeloid Sequencing (TARMED-Pos. 3x : 1' TP) Bone marrow biopsy / punch in NaCl, Monday Thursday, at latest 17:30 Bone marrow aspirat or blood, Monday Thursday, at latest 17:30, Friday at latest 14:00 Analysis from EDTA-Blood and plasma possible (): Lung cfdna Assay (DNA) (TARMED-Pos. 5x : 2'353 TP) (DNA) (TARMED-Pos. 5x : 2'353 TP) Breast cfdna Assay (DNA) (TARMED-Pos. 5x : 2'353 TP) Send ml blood in a K2-EDTA Plasma tube within 12 h at room temperature to the USZ (at latest 16:00). Please provide date and time from blood taking. If the sample cannot be sent within 12 h, please use following tube: Cell-Free DNA BCT (Streck; Katalog-Nr.: ) and send it to the address depicted above at room temperature. Please provide date and time from blood taking. If you do not have such tubes, we may send you one. 7FO-Einsendeformular_SP_englisch_ PTK.docx Seite 5 von 5
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