BIOPSY REQUEST FORM

MUSCLE / NERVE BIOPSY REQUEST FORM
Neuromuscular Clinical Laboratory: Alan Pestronk, M.D., Director
Washington University School of Medicine – Neurology Department
Internet Home Page http://neuromuscular.wustl.edu

Referring institution	Patient name
Requesting physician	Sex Age Birth date
Send report to NAME ADDRESS CITY, STATE, ZIP PHONE & FAX #	Date biopsy performed
	Date biopsy received
	WU Lab accession #
Bill charges to Labs other than Washington University: If we are billing patient, please provide insurance authorization number.

Clinical Diagnosis & History

Specimens & Site biopsied

Surgeon

INSTRUCTIONS
   Hand carried fresh tissue: Wrap in moist (saline) gauze; Do not immerse in saline or fixative
   Mailed tissue: NOTES - Laboratory only open Monday through Friday; Send by overnight mail for early next day delivery
Method A. Freeze one piece of tissue in isopentane cooled with liquid nitrogen; Fix a 2nd piece, or
Method B. Wrap biopsy specimens in moist (saline) gauze. Place in sealed plastic container. Send on cold packs. Do not freeze.

TESTS REQUESTED: Histochemical & Immunocytochemical stains are performed on frozen, unfixed tissue.
  Routine Histochemistry: Performed on all biopsies
[ ] MUSCLE: H&E X 2, NADH, GT, ATPase X 3, VvG, Congo Red, Sudan Black, Alkaline & Acid Phosphatase, Esterase
Periodic Acid Schiff, Cytochrome Oxidase, Succinic Dehydrogenase, Amylo-phosphorylase, AMPDA
[ ] NERVE Frozen sections: H&E, GT, Congo Red, Alkaline & Acid Phosphatase, VvG, Neurofilament Plastic sections: Toluidine blue
NEUROPATHOLOGY reports additional information covering the nerve biopsy in a separate report.
Dystrophies (Immunocytochemistry (IHC) ± Western blot (WB)): [ ] Dystrophy-related protein panel
[ ] Dystrophin (IHC); [ ] Dystrophin (WB); [ ] Sarcoglycans (α, β, δ, γ) (IHC); [ ] Sarcoglycans (WB); [ ] Caveolin (IHC & WB);
[ ] Emerin (IHC & WB); [ ] Desmin (IHC); [ ] α-Dystroglycan (IHC); [ ] Laminin α2 & B (IHC); [ ] Collagen VI & IV (IHC);
[ ] Dysferlin (IHC & WB); [ ] Calpain 3 (WB); [ ] VCP (IHC); [ ] LAMP-2; [ ] Phosphorylated tau (SMI-31); [ ] α-actinin
Immune myopathy panel: [ ] MHC Class I; Capillary morphology (Ulex); C5b-9 (MAC); CD4; CD20; CD11b; Decorin; IgM deposition
Aggregate panel: [ ] Desmin; VCP; α-actinin; Caveolin; Ubiquitinated proteins (FK2); Phosphorylated tau (SMI-31)
BIOCHEMISTRY Performed at Washington University Neuromuscular Lab EXTRA SPECIMEN usually required (> 0.5 cm³, 100 mg)
Mitochondrial oxidative enzymes: [ ] Activity (Complexes I, II, II + III (± Decylubiquinone), III, IV, Citrate synthase); [ ] Western blot (Complexes I-V)
[ ] Coenzyme Q10; [ ] Glycogen + Acid Maltase; [ ] PFK histochemistry; OTHER______________________________________

Requirements for tissue to be forwarded from our Neuromuscular lab to other labs for further testing
Extra specimen (minimum 0.5 cm³, 200 to 500 mg); Clinical information; Billing information & approval #; Patient release, signed;
Completed requisition from testing lab; Minimum amount of tissue needed for testing; Shipping address, information & form

SHIPPING ADDRESSES
Frozen specimens	Fresh tissue -- HAND DELIVERY
SHIPPING/MAILING ADDRESS: ALAN PESTRONK, M.D. Washington University - Neurology, Box 8111 660 S. Euclid Ave. St. Louis, MO 63110	STREET LOCATION: NEUROMUSCULAR LABORATORY Irene Walter Johnson Institute 509 S. Euclid, Room 404 St. Louis, MO 63110
Phone: 314-362-6981 (Office); 314-362-2406 (Lab); FAX: 314-362-3752	CAP# 19233-16 : CLIA ID# 26D0652044 : Medicare Provider # 26-8235
Turn around time: ~3 to 4 weeks	pestronka@neuro.wustl.edu Revised 2/15/2008 GJP/AP