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(IHC)/In Situ Hybridization (ISH) Stains Request Form Immunohistochemical (IHC)/ In Situ Hybridization (ISH) Stains Request Client Information (required) Patient Information (required) Client Name Patient ID (Medical Record No.) Client Account No. Patient Name (Last, First, Middle) Client Phone Client Order No. Sex Birth Date (mm-dd-yyyy) Male Female Address Collection Date (mm-dd-yyyy) Time am pm City State ZIP Code Street Address City State ZIP Code Submitting Provider Information (required) Submitting/Referring Provider Name (Last, First) Phone Fill in only if Call Back is required. Specimens Provided (required) Phone (with area code) Fax (with area code) Paraffin block Specimen Source Provider’s National I.D. (NPI) No. sent _________ *Fax number given must be from a fax machine that complies with applicable Cut slides HIPAA regulation. No. sent _________ “I hereby confirm that informed consent has been signed by an individual legally authorized to do so and is on file with this office or the individual’s provider’s office.” MCL Internal Use Only Signature Note: It is the client’s responsibility to maintain documentation of the order. Ship specimens to: Billing Information Mayo Clinic Laboratories • An itemized invoice will be sent each month. 3050 Superior Drive NW • Payment terms are net 30 days. Rochester, MN 55901 Call the Business Office with billing related questions: Customer Service: 855-516-8404 800-447-6424 (US and Canada) 507-266-5490 (outside the US) Visit www.MayoClinicLabs.com for the most up-to-date test and shipping information. T763 ©2021 Mayo Foundation for Medical Education and Research Page 1 of 4 MC0767-09Arev0721 Patient Information (required) Patient ID (Medical Record No.) Client Account No. Patient Name (Last, First, Middle) Client Order No. Birth Date (mm-dd-yyyy) THERAPEUTIC AND PROGNOSTIC IN SITU HYBRIDIZATION (ISH) STAINS- BOB1 BOB-1 MARKERS WITH INTERPRETATION TECHNICAL COMPONENT ONLY WITHOUT BRACH Brachyury INTERPRETATION Pathology report with final diagnosis required BRAFV BRAF V600E for each case submitted. EBV Epstein-Barr Virus (EBV) BRG1 BRG1 (SMARCA4) Multiple blocks, select 1: KLISH Kappa and Lambda Light Chain mRNA Choose best block Perform on all blocks CRPRO C Reactive Protein RSVAB Respiratory Syncytial Virus (RSV) ERPR Estrogen/Progesterone Receptor, CALCI Calcitonin Semi-Quantitative Immunohistochemistry, IN SITU HYBRIDIZATION (ISH) STAINS CALD Caldesmon Manual WITH INTERPRETATION CALPN Calponin KI67B Ki-67(MIB-1), Breast, Quantitative HPVHL Human Papillomavirus (HPV) CALRC Calreticulin ex9mut Immunohistochemistry, Automated High/Low Risk, DNA CALNN Calretinin KI67P Ki-67(MIB-1), Pulmonary, Quantitative HPVHR Human Papillomavirus (HPV), Immunohistochemistry, Automated High-Risk, DNA CAMTA CAMTA1 KINET Ki-67(MIB-1), Gastrointestinal/Pancreatic HPVLR Human Papillomavirus (HPV), CAIX Carbonic Anhydrase IX (CA-IX) Neuroendocrine Tumors, Quantitative High-Risk, DNA CTSK Cathespin K Immunohistochemistry, Automated HPVE6 Human Papillomavirus (HPV) CD10 CD10 HER2 Immunohistochemistry (IHC) Testing High-Risk E6/E7, RNA CD103 CD103 Was specimen fixed in 10% neutral buffered formalin JCV JC Virus Detection within 1 hour from surgical collection time? CD11C CD11c Yes No IMMUNOHISTOCHEMICAL (IHC) STAINS- CD123 CD123 Has specimen been fixed in 10% neutral buffered TECHNICAL COMPONENT ONLY WITHOUT CD13 CD13 formalin for 6 to 72 hours? INTERPRETATION Yes No CD138 CD138 (Syndecan) ABCRS A/B Crystallin Tissue was decalcified? CD14I CD14 ACTHI ACTH Yes No Unknown CD15 CD15 SMACN Actin, Smooth Muscle HERBA HER2, Breast, Quantitative CD163 CD163 Immunohistochemistry, ADV Adenovirus CD19BM CD19 Bone Marrow Automated with HER2 FISH Reflex ALK ALK HER2, Breast, Quantitative CD19I CD19 HERBN AATRP Alpha-1-Antitrypsin Immunohistochemistry, Automated, CD1A CD1a No Reflex AFSH Alpha FSH CD2 CD2 HERDM HER2, Breast, Quantitative ASYN Alpha Synuclein CD2B CD2 Immunohistochemistry, Automated, ALFP Alpha-Fetoprotein No Reflex CD20I CD20 AMYA Amyloid (SAA) HERDN HER2, Breast, DCIS, Quantitative CD21 CD21 AAH Amyloid A (Hepatic) Immunohistochemistry, Manual No Reflex CD22I CD22 HER2, Breast, DCIS, Quantitative AMYPI Amyloid P (SAP) HERGM CD23 CD23 Immunohistochemistry, Manual No Reflex AREC Androgen Recep CD25 CD25 HERGN HER2, Breast, DCIS, Quantitative ANNEX Annexin-1 Immunohistochemistry, Manual No Reflex CD273 CD273 (PD-L2) APPI APP CD279 CD279 (PD-1) SPECIAL IMMUNOHISTOCHEMISTRY (IHC) ARGIN Arginase-1 CD3I CD3 STAINS WITH INTERPRETATION ASCL1 ASCL1 (hASH1) CD30 CD30 DLL3 Delta-Like 3 Protein (DLL3) (SP347), ATRX ATRX Semi-Quantitative Immunohistochemistry, CD303 CD303 (BDCA-2) Manual, Tissue BAP1 BAP1 CD31 CD31 SP263 Programmed Death-Ligand 1 BCATN B-Catenin CD33 CD33 (PD-L1) (SP263), Semi-Quantitative BEREP Ber-EP4 Immunohistochemistry, Manual CD34I CD34 BCL2 BCL-2 22C3 Programmed Death-Ligand 1 CD35 CD35 BCL6 BCL-6 (PD-L1) (22C3), Semi-Quantitative CD38 CD38 Immunohistochemistry, Manual BCOR BCOR CD4I CD4 SP142 Programmed Death-Ligand 1 FSHB Beta FSH (PD-L1) (SP142), Semi-Quantitative CD43 CD43 LUTHI Beta LH Immunohistochemistry, Manual CD45I CD45 (LCA) TSH Beta TSH BAMY Beta-Amyloid T763 Page 2 of 4 MC0767-09Arev0721 Patient Information (required) Patient ID (Medical Record No.) Client Account No. Patient Name (Last, First, Middle) Client Order No. Birth Date (mm-dd-yyyy) CD5 CD5 IHCFH Fumarate Hydratase JCHAI J-Chain CD56 CD56 FUSI FUS KAIHC Kappa CD57 CD57 GAB1 GAB1 KRT34 Keratin (34BE12) CD61 CD61 GALN3 Galectin-3 KRTAE Keratin (AE1/AE3) CDKPB CD68 (KP1) GASTN Gastrin KRTCA Keratin (CAM 5.2) CDKP1 CD68 (KP1) GATA3 GATA3 KRTOS Keratin (OSCAR) PGM1 CD68 (PG-M1) GATAB GATA3, Bone Marrow KRT19 Keratin 19 CD7 CD7 GCDF GCDFP-15 KRT20 Keratin 20 CD71 CD71 GCET GCET1 KRT5 Keratin 5 CD79 CD79a GFAP GFAP KRT7 Keratin 7 CD8I CD8 GLUCG Glucagon KI67 Ki-67 (MIB-1) CD99 CD99 (MIC-2) GLUT GLUT-1 KIMEL Ki67+ Melan A CDX2 CDX2 GLUTS Glutamine Synthetase KIT KIT HCG Chorion Gonadotropin GLYCF Glycophorin A LACTO Lactotransferrin CHRO Chromogranin GLYP3 Glypican-3 LAIHC Lambda CLAUD Claudin-1 GRANB Granzyme B LANGR Langerin CLDN4 Claudin-4 GRH Growth Hormone LATI LAT CLUS Clusterin HPYL H. pylori LECT2 LECT2 CMET cMET DBA4 Hairy Cell (DBA44) LEF1 LEF1 COLIV Collagen IV HBME HBME-1 LFABP L-FABP CO4D Complement 4d HEMB Hemoglobin LMO2 LMO2 COX2 COX-2 HEPBC Hepatitis B core LYSOZ Lysozyme CYC1 Cyclin D1 HEPBS Hepatitis B surface MALI MAL CMVI Cytomegalovirus HEPAT Hepatocyte MGB Mammaglobin CXC13 CXCL13 HER2I HER2 MCEA M-CEA DESMN Desmin HRPV8 Herpes Virus type 8 MELAN Melan A (MART-1) DESG3 Desmoglein 3 HG34W Histone H3 G34W MERKC Merkel CC (MCPyV) DNJB9 DNAJB9 HK27M Histone H3 K27M MTAP Methylthioadenosine Phosphorylase (MTAP) DOG1 DOG-1 HISME Histone3 K27me3 MITF MiTF EBNA2 EBNA2 HK36M H3F3 K36M MLH1 MLH1 LMP1I EBV-LMP1 HMB45 HMB45 MOC31 MOC-31 ECAD E-Cadherin HMGA HMGA2 MSH2 MSH2 ECADB E-Cadherin, Bone Marrow HNF1B HNF-1beta MSH6 MSH6 EMAI EMA HRPSV HSV I and II MUCN2 Mucin 2 ERG ERG ICOSI ICOS (CD278) MUCN4 Mucin 4 ERBE1 Estrogen Rec Beta1 IDH1 IDH1-R132H MUCN5 Mucin 5AC ESTR Estrogen Rec IGAI IgA MUCN6 Mucin 6 FC13A Factor 13a IGDI IgD MUM1 MUM-1/IRF4 FACR8 Factor 8 R Ag IGGI IgG MUM1B MUM-1(IRF4) Bone Marrow FASC Fascin IGG4I IgG4 MYC MYC FGFRC FGFR1 IGMI IgM MYPO Myeloperoxidase 3FBLN Fibulin 3 INHIB Inhibin MYOD1 MYOD1 FLI1 FLI-1 INI1 INI1/BAF47 MYOGE Myogenin BFOS FosB INSUL Insulin MYOGL Myoglobin FOXP1 FOXP1 INSM1 INSM1 FOXP3 FOXP3 ISLET Islet 1 T763 Page 3 of 4 MC0767-09Arev0721 Patient Information (required) Patient ID (Medical Record No.) Client Account No. Patient Name (Last, First, Middle) Client Order No. Birth Date (mm-dd-yyyy) NAPSN Napsin A SMOTH Smoothelin NEGCT Negative Control SOMAT Somatostatin NELL1 NELL1 SSTR2 Somatost Rc2 (SSTR2) NEUN Neu-N SOX10 SOX10 NF2F Neurofilament (2F11) SOX11 SOX11 NFSMI NF (SMI31) STAT6 STAT6 NSEI NSE SYNAP Synaptophysin NKX3 NKX3.1 SSX18 Synovial Sarcoma Panel NUT NUT TAU3 TAU 3 OCT2 OCT-2 TAU4 TAU 4 OCT4 OCT-4 TAUI TAU OLIG2 OLIG2 TBET T-BET P16 p16 (INK4a/CDKN2A) BTIA1 T-Cell Intracellular Antigen 1, Bone Marrow P40NA p40 + Napsin A TCL1A TCL1A P40 p40 TCRF1 TCR Beta F1 P53 p53 TCRGD TCR Delta P57I p57 (KIP2/CDKN1C) TDT TdT P62 p62 TFE3I TFE3 P63 p63 THYR Thyroglobulin PACPI PACP TIA1 TIA-1 PFIB Parafibromin TLE1 TLE-1 PTH Parathyroid Hormone TOXO Toxoplasma PARVI Parvovirus TPIT T-PIT PAX2 PAX-2 TRAP TRAP PAX5 PAX-5 TREPE Treponema Pallidum PAX8 PAX8 TRK TRK PCEAI P-CEA TRYPN Trypsin PHTDP Phospho TDP43 TRPTS Tryptase PIN2 PIN2 (p63/p504S) TTF8G TTF1 (8G7G3/1) PIT1 Pit-1 TTFSP TTF1 (SPT24) HPL Placental Lactogen TTFK5 TTF1(SPT24) + KRT5 PLAP PLAP TTF40 TTF1 (SPT24) + p40 PMS2 PMS2 TYROS Tyrosinase D240 Podoplanin (D2-40) UBIQ Ubiquitin PROG Progesterone Rec VIM Vimentin PRLI Prolactin VIPI VIP PSAIM Prostate Spec Ag VZV VZV PTRIP Prostate Triple (P63/KRT/P504S) WT1I Wilm’s Tumor (WT-1) PU1 PU.1 YAP1 YAP1 RB1 Retinoblastoma BTB46 ZBTB46 S100 S-100 SALL4 SALL4 SATB2 SATB2 2SC S-(2-Succinyl)-Cysteine (2SC) SDHB SDHB SF1 SF-1 T763 Page 4 of 4 MC0767-09Arev0721.
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