Laboratory Form or Record - QEHB Pathology
HEAD & NECK CARCINOMA
PDL1 EXPRESSION TESTING PRIOR TO PDL1/PD1 THERAPY
PD-L1 22C3 pharmDx IHC FOR PEMBROLIZUMAB (
PD-L1 28-8 pharmDx IHC FOR NIVOLUMAB (
Patient details
Surname: .............................................. Forename: ……………………………….. DOB: ……..…………
Requesting Physician
Name: ………………………………………………..
Hospital Name and Address: …...........................................................................................………………
..................................................................................................................................................................................................................
Postcode: ..................... Tel: ............................ Fax: ............................... Email: ......................................
Pathology details
Pathology Hospital ……………………………………… Report/Pathology number ……………………………
If sending cut sections, please enter date of cutting, length of drying and drying temperature here
Date ______________ Drying Temp _____________ Drying length _______________
Invoicing Information (please also give an indication whether physician or pathologist to be invoiced)
-----------------------
Requesting Physician / Oncologist ………………………………………………………………………..
Physician / Oncologists Hospital / Trust ………………………………………………………………………..
(Name, email and Full Postal Address) ………………………………………………………………………..
Referring Pathologist ………………………………………………………………………..
Pathologists Hospital / Trust (if different) ………………………………………………………………………..
(Name, email and Full Postal Address) ………………………………………………………………………..
Hospital where the patient is being treated ………………………………………………………………………..
Purchase Order Number (if available) ………………………………………………………………………..
MDT Coordinator(s) ………………………………………………………………………..
(Name, email and Full Postal Address) ………………………………………………………………………..
Specimen Requirements:
PDL1 expression testing
• A sample of tumour (paraffin block from biopsy or tumour resection, or a cell block) or unstained mounted sections from the tumour (minimum of 3 slides per test).
• Unstained slides for testing should be cut at 4um and mounted on Agilent FLEX slides.
• Please note tissue handling, tissue fixation, time between cutting and staining and excessive drying can lead to loss of expression
• A copy of the original Pathology report where possible.
Residual material will be returned to you as soon as possible.
Please send material to:
The Molecular Pathology Diagnostic Service
Department of Cellular Pathology
Level -1
Queen Elizabeth Hospital Birmingham
Mindelsohn Way, Edgbaston
Birmingham, B15 2WB
Molecular Pathology Contact Details
GENERAL ENQUIRES –
Tel: 0121 3713320/3713325 mpds.enquiries@
Dr Phillipe Taniere: Clinical Service Lead
Tel: 0121 371 3350 Phillipe.taniere@
Mr Brendan O’Sullivan: Operations Manager
Tel: 0121 371 3351 Brendan.O’Sullivan@
Dr Matthew Smith: Principal Clinical Scientist
Tel: 0212 371 3312 Matthew.Smith24@
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