IMMUNOHISTOCHEMISTRY TECH-ONLY REQUISITION Michigan Medicine Laboratories (MLabs) N-LNC Specimen Processing Client Patient Reg or MRN: 2800 Plymouth Rd,Bldg 35 Ann Arbor, MI 48109-2800 Patient Name: Last First MI 734.936.2598 • 800.862.7284 • mlabs.umich.edu Ward Birthdate: Gender: M F FAX: 734.936.0755 Ordering Doctor: Last First NPI# Bill To: n Client/Referring Institution REFERRING PHYSICIAN TO BE CONTACTED WITH RESULTS AND/OR QUESTIONS Referring Physician Referring Institution Phone Fax Address City State ZIP Country MATERIALS SENT Specimen ID:___________________________________________ __________________________ Block ID: _______________________ Collection Date:____________________________ Fixative/Preservative: _____________________________________________________________ Diagnosis ____________________________________________________________________ Body Site: ______________________________________________________________________________________________________________________________________________________ n FNA Cell Block: _________________________________________________________________ n Stained (type of stain) ______________________________________________________ n Slide # ___________________ Unstained ___________________ Stained ___________________ n H & E _______________________________________________________________________ n Paraffin Block(s) #: ______ n Choose best block n Perform tests on all blocks If you need assistance in stain selection, please contact MLabs Client Services. If sending slides, 2 extra slides per test are required. IHC/ISH Stains n A-1 ANTICHYMOTRYPSIN n CD 13 n DESMIN n IGG n P16 n STAT6 (A-1 ACT) n CD 14 n DOG-1 n IGG4 n P53 n SV40 n A-1 ANTITRYPSIN (A-1 AT) n CD 15 n E-CADHERIN n IGM n P57 n SYNAPTOPHYSIN n A-B CRYSTALLIN n CD 19 n EBER-ISH n INHIBIN n P63 n SYNUCLEIN n ACTH n CD 20 n EGFR n INI-1 n PARVOVIRUS n TAU n ADENOVIRUS n CD 21 n EMA n KAPPA-IHC n PAX-2 n TCL1 n AE1/AE3 n CD 23 n ERG n KAPPA-ISH n PAX-5 n TCR DELTA n AFP n CD 25 n F-MYOSIN n KI-67 n PAX-8 n TCR BF1 n ALK (D5F3) n CD 30 n F13A n LAMBDA-IHC n PD-1 n TDP-43 n AMACR (P504S) n CD 31 n FASCIN n LAMBDA-ISH n PGP9.5 n TDT n AND-REC (AR) n CD 33 n FH n LEF1 n PHH3 n TFE3 n ANNEXIN n CD 34 n FOXP1 n LFABP n PIN 4 n THYROGLOBULIN n ARGINASE-1 n CD 43 n FSH n LH n PLAP n TIA1 n ATRX n CD 45 n FVIIIRA n LYSOZYME n PR-CKCTL n TLE-1 n B-AMYLOID n CD 56 n GASTRIN n MAMMAGLOBIN (34ßE12 & p63) n TOXOPLASMA n n B-CATENIN n CD 57 n GATA-3 n MAST CELL TRYPTASE PRAME n TRAP n n B72.3 n CD 61 n GFAP n MDM2 PRAP n TRYPSIN n n BAP1 n CD 68 n GH n MELAN A PREALBUMIN n TSH n n BCL-10 n CD 79A n GLYPICAN-3 n MITF PROLACTIN n TTF1 n n BCL-2 n CD 99 n GLUT SYNTH n MNF116 PROX1 n TYROSINASE n n BCL-6 n CD 117 (CKIT) n GLUT1 n MOC-31 PSA n UBIQ n n BER-EP4 n CD 123 n GLY-A n MS ACTIN PSMA n VIMENTIN n n BOB.1 n CD 138 n GRANZYME n MUC2 pTDP-43 n VZV n n BRACHY n CD 163 n H. PYLORI n MUC4 PTH n WT1 n n BRAF-V600E n CDX-2 n H3.3 G34W n MUC5AC PU.1 MMR n n n n BRST-2 n CEA-M n H3K27M n MUC6 RB MLH1 MSH2 n n n PMS2 n MSH6 C-MYC n CEA-P n H3K27me3 n MUM1 RCC n n n with interpretation C4D n CHROMOGRANIN n HCG n MYELIN BASIC PROTEIN S-MYOSIN n n ER (SP1) CA-IX n CHYMOTRYPSIN n HEMO-A n MPO S100 n Coreo interpretation n n n CALCITONIN n CK 19 n HEPAT (HEP PAR) n MYOGENIN S100-A1 no interpretation n n CALDESMON n CK 20 n HEP-CORE n MYOD1 SAA PR (1E2) n n n Coreo interpretation CALPONIN n CK 5/6 n HEP-SURFACE n NAPSIN SALL4 n n n no interpretation CALRETININ n CK 7 n HHV8 n NESTIN SATB2 n n HER-2 (4B5) CAM5.2 n CK 903 n HMB-45 n NEUN SDHB n Coreo interpretation n n CAMTA1 n CKCKTL (AE1/AE3 & CAM5.2) n HPL n NEUROFIL SF-1 (2+ reflex to FISH) n n n CD 1A n CLAUDIN-4 n HPV HR-ISH n NGFR SEROTONIN no interpretation n n CD 2 n CLUSTERIN n HPV-LR ISH n NKI/C3 SM ACTIN PD-L1 (22C3 Lung) n n n with interpretation CD 3 n CMV n HSV 1 n NKX3.1 SM MYOS n CD 4 n SMARCA4 PD-L1 (22C3 Gastric/ n COLLAGEN IV n HSV 2 n NSE Gastroesophageal n n CD 5 n CRP n ICOS n NUT SOX2 Adenocarcinoma) n n n CD 7 n CYCD1 n IDH1 n OCT-2 SOX10 with interpretation n n CD 8 n D2-40 n IGA n OCT-4 SOX11 PD-L1 (SP142 breast) n n n CD 10 n DBA.44 n IGD n OLIG2 SPIROCHETE with interpretation Pathology report required to accompany the materials Requires 3 slides for testing Requires 2 slides for testing Requires H&E slide included The availability of IHC/ISH tests listed on this requisition may be revised by the testing laboratory at any time. Visit www.mlabs.umich.edu for the most up-to-date test information. Revised: 08-12-2020.