Memorandum Date: October 10, 2012 To: Edmonton, Central, North and South Zones: Laboratory Directors, Managers, Pathologists and Anatomic Pathology Staff at: Grey Nuns Community Hospital, Misericordia Community Hospital, Royal Alexandra Hospital, University of Alberta Hospital, DynaLifeDx Red Deer Regional Hospital Bonnyville Healthcare Centre, Queen Elizabeth II Hospital, Northern Lights Regional Health Centre - DynaLifeDx Chinook Regional Hospital, Medicine Hat Regional Hospital and Medicine Hat Diagnostic Laboratory From: AHS Laboratory Services – Edmonton Zone RE: Edmonton Zone IHC Laboratory Breast Biomarker Requests Please be advised that the Edmonton Zone Immunohistochemistry Laboratory (EZIHC Lab) requires a “Breast Biomarker Requests” form to be completed for all Biomarker requests including requests from within the Edmonton zone. Along with each completed form, a copy of the report with a diagnosis must also be submitted to the EZIHC Lab. Information that must be provided: • Patient Identification • Original Accession number • Collection Date • Reporting Pathologist • Specimen Type • Material Sent • Diagnosis information • Report type Additionally, fixation data must also be provided. The requesting laboratory must provide information about the fixative used, the devitalization time and the duration of fixative exposure. A copy of the most up to date Breast Biomarker Requests form is provided. Questions or concerns may be directed to: Dr. Gilbert Bigras, Medical Lead, Edmonton Zone IHC Laboratory [email protected] or 780-432-8445 Robin Stocks, Technologist II Supervisor, Edmonton Zone IHC Laboratory [email protected] or 780-577-8122 Edmonton • Cross Cancer Institute • Laboratory Medicine & Pathology Rm. 2338, 11560 University Avenue, Edmonton, Alberta, Canada T6G 1Z2 www.albertahealthservices.ca Edmonton Zone Immunohistochemistry Laboratory Department of Laboratory Medicine and Pathology Cross Cance r Institute 11560 University Avenue, Edmonton, AB T6G 1Z2 Ph. 780.432.8587 Fax. 780.432.8455 BREAST BIOMARKER REQUESTS PATIENT NAME: __________________________________________________________ PHN: _____________________________DOB (DD/MM/YYYY): _____________________ ORIGINAL ACCESSION NO: __________________________ BLOCK NO: __________ COLLECTION DATE: ________________ PATHOLOGIST: _______________________ SPECIMEN TYPE (e.g., segmental, needle core, etc): ___________________________ MATERIAL SENT (e.g., block, slide, etc): _____________________________________ DIAGNOSIS: Invasive Carcinoma DCIS Only PRELIMINARY Report FINAL Report FIXATION DATA FIXATIVE: 10% NEUTRAL BUFFERED FORMALIN CONFIRMED OTHER (please specify): ______________________________________ DEVITALIZATION TIME: _______ hours ______ min Time delay before formalin exposure (normally less than 1 hour i.e. 0 hour 42 minutes). This would essentially capture any delays between surgical resection / specimen collection and adequate formalin exposure (sliced when necessary). This should reflect any delays encountered for transport, specimen imaging or slicing of large specimens (into 1 cm or less tissue slices) prior to tumor exposure to formalin. TIME IN FIXATIVE: ________ hours _______min Time duration of formalin exposure (# hours ie. TOTAL to nearest hour – also including hours of processor formalin steps as well 0,1,2,3,4,5,6…999 etc.) (Rev October 2012) .