SIST-TS CEN/TS 17742:2022
(Main)Molecular in vitro diagnostic examinations - Specifications for pre-examination processes for venous whole blood - Isolated circulating cell free RNA from plasma
Molecular in vitro diagnostic examinations - Specifications for pre-examination processes for venous whole blood - Isolated circulating cell free RNA from plasma
This document gives guidelines on the handling, storage, processing and documentation of venous whole blood specimens intended for circulating cell free RNA (ccfRNA) examinations during the pre-examination phase before a molecular examination is performed. This document covers specimens collected in venous whole blood collection tubes.
The pre-examination process described in this document results in circulating cell free RNA isolated from blood plasma without prior enrichment of exosomes and other extracellular vesicles.
This document is applicable to molecular in vitro diagnostic examinations performed by medical laboratories. It is also intended to be used by laboratory customers, in vitro diagnostics developers and manufacturers, biobanks, institutions and commercial organizations performing biomedical research, and regulatory authorities.
Different dedicated measures are taken during the pre-examination phase for isolated RNA from enriched exosomes and other extracellular vesicles enriched from venous whole blood and for cellular RNA isolated from venous whole blood. These are not described in this document but are covered in CEN/PWI, Molecular in vitro diagnostic examinations — Specifications for pre-examination processes for exosomes and other extracellular vesicles in venous whole blood — Isolated DNA, RNA and proteins, and in ISO 20186-1, Molecular in vitro diagnostic examinations — Specifications for pre-examination processes for venous whole blood — Part 1: Isolated cellular RNA.
NOTE International, national or regional regulations or requirements can also apply to specific topics covered in this document.
Molekularanalytische in-vitro-diagnostische Verfahren - Spezifikationen für präanalytische Prozesse für venöse Vollblutproben - Isolierte zirkulierende zellfreie RNA aus Plasma
Dieses Dokument legt Anforderungen und Empfehlungen für die präanalytische Phase der Untersuchung zirkulierender zellfreier RNA (ccfRNA) aus venösen Vollblutproben fest, unter anderem für die Entnahme, Handhabung, Lagerung, Verarbeitung und Dokumentation von venösen Vollblutproben, die für die ccfRNA-Untersuchung vorgesehen sind. Dieses Dokument betrifft Untersuchungsmaterial, das mit Blutentnahmeröhrchen für venöses Vollblut entnommen wurde.
Mit dem in diesem Dokument beschriebenen präanalytischen Verfahren wird zirkulierende zellfreie RNA ohne vorherige Anreicherung von Exosomen und anderen extrazellulären Vesikeln aus dem Blutplasma isoliert.
Dieses Dokument ist anwendbar auf molekulare in-vitro-diagnostische Untersuchungen, die in medizinischen Laboratorien durchgeführt werden. Es soll auch von Laborkunden, Entwicklern und Herstellern von In-vitro-Diagnostika, Biobanken, Einrichtungen und kommerziellen Organisationen, die in der biomedizinischen Forschung tätig sind, sowie Aufsichtsbehörden eingesetzt werden.
Während der präanalytischen Phase müssen für RNA, die aus angereicherten Exosomen und aus anderen aus venösem Vollblut angereicherten extrazellulären Vesikeln isoliert wurde, und für aus venösem Vollblut isolierte zelluläre RNA verschiedene spezielle Maßnahmen getroffen werden. Diese sind in diesem Dokument nicht beschrieben, sondern werden in CEN/TS 17747, Molekularanalytische in‑vitro-diagnostische Verfahren — Spezifikationen für präanalytische Prozesse für Exosomen und andere extrazelluläre Vesikel im venösen Vollblut — Isolierte DNA, RNA und Proteine, und in EN ISO 20186-1, Molekularanalytische in-vitro-diagnostische Verfahren — Spezifikationen für präanalytische Prozesse für venöse Vollblutproben — Teil 1: Isolierte zelluläre RNA, behandelt.
ANMERKUNG Internationale, nationale oder regionale Regelungen bzw. Anforderungen können ebenfalls für bestimmte Themen in diesem Dokument gelten.
Analyses de diagnostic moléculaire in vitro — Spécifications relatives auc processus préanalytiques pour le sang total veineux — ARN libre circulant extrait du plasma
Molekularne diagnostične preiskave in vitro - Specifikacije za predpreiskovalne procese za vensko polno kri - Iz plazme izolirana cirkulirajoča brezcelična RNK
Ta dokument podaja smernice glede obravnave, shranjevanja, obdelave in dokumentiranja vzorcev venske polne krvi, namenjenih za analizo krožeče brezcelične RNK (ccfRNA) med predpreiskovalno fazo, preden se izvede molekularna preiskava. Ta dokument zajema vzorce, ki so zbrani s cevkami za zbiranje venske polne krvi.
Predpreiskovalni proces, opisan v tem dokumentu, vključuje cirkulirajočo brezcelično RNK, izolirano iz krvne plazme brez predhodne obogatitve eksosomov in drugih zunajceličnih veziklov.
Ta dokument se uporablja za molekularne diagnostične preiskave in vitro, ki jih izvajajo v medicinskih laboratorijih. Namenjen je tudi temu, da ga uporabljajo laboratorijske stranke, razvijalci in proizvajalci diagnostike in vitro, biobanke, institucije in komercialne organizacije, ki izvajajo biomedicinske raziskave, ter regulativni organi.
V predpreiskovalnem procesu se izvajajo različni namenski ukrepi za izolirano RNK iz obogatenih eksosomov in drugih zunajceličnih veziklov, obogatenih iz venske polne krvi, in za celično RNK, izolirano iz venske polne krvi. Ti niso opisani v tem dokumentu, vendar so zajeti v standardu CEN/PWI, Molekularne diagnostične preiskave in vitro – Specifikacije za predpreiskovalne procese za eksosome in druge zunajcelične vezikle v vensko polni krvi – Izolirana DNK, RNK in beljakovine ter v standardu ISO 20186-1, Molekularne diagnostične preiskave in vitro – Specifikacije za predpreiskovalne procese za vensko polno kri – 1. del: Izolirana celična RNK.
OPOMBA: Za določene teme, ki so zajete v tem dokumentu, lahko veljajo tudi mednarodni, nacionalni ali regionalni predpisi ali zahteve.
General Information
Standards Content (Sample)
SLOVENSKI STANDARD
SIST-TS CEN/TS 17742:2022
01-junij-2022
Molekularne diagnostične preiskave in vitro - Specifikacije za predpreiskovalne
procese za vensko polno kri - Iz plazme izolirana cirkulirajoča brezcelična RNK
Molecular in vitro diagnostic examinations - Specifications for pre-examination processes
for venous whole blood - Isolated circulating cell free RNA from plasma
Molekularanalytische in-vitro-diagnostische Verfahren - Spezifikationen für
präanalytische Prozesse für venöse Vollblutproben - Isolierte zirkulierende zellfreie RNA
aus Plasma
Analyses de diagnostic moléculaire in vitro — Spécifications relatives auc processus
préanalytiques pour le sang total veineux — ARN libre circulant extrait du plasma
Ta slovenski standard je istoveten z: CEN/TS 17742:2022
ICS:
11.100.10 Diagnostični preskusni In vitro diagnostic test
sistemi in vitro systems
SIST-TS CEN/TS 17742:2022 en,fr,de
2003-01.Slovenski inštitut za standardizacijo. Razmnoževanje celote ali delov tega standarda ni dovoljeno.
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SIST-TS CEN/TS 17742:2022
CEN/TS 17742
TECHNICAL SPECIFICATION
SPÉCIFICATION TECHNIQUE
March 2022
TECHNISCHE SPEZIFIKATION
ICS 11.100.10
English Version
Molecular in vitro diagnostic examinations - Specifications
for pre-examination processes for venous whole blood -
Isolated circulating cell free RNA from plasma
Molekularanalytische in-vitro-diagnostische Verfahren
- Spezifikationen für präanalytische Prozesse für
venöse Vollblutproben - Isolierte zirkulierende
zellfreie RNA aus Plasma
This Technical Specification (CEN/TS) was approved by CEN on 14 February 2022 for provisional application.
The period of validity of this CEN/TS is limited initially to three years. After two years the members of CEN will be requested to
submit their comments, particularly on the question whether the CEN/TS can be converted into a European Standard.
CEN members are required to announce the existence of this CEN/TS in the same way as for an EN and to make the CEN/TS
available promptly at national level in an appropriate form. It is permissible to keep conflicting national standards in force (in
parallel to the CEN/TS) until the final decision about the possible conversion of the CEN/TS into an EN is reached.
CEN members are the national standards bodies of Austria, Belgium, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia,
Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Norway,
Poland, Portugal, Republic of North Macedonia, Romania, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland, Turkey and
United Kingdom.
EUROPEAN COMMITTEE FOR STANDARDIZATION
COMITÉ EUROPÉEN DE NORMALISATION
EUROPÄISCHES KOMITEE FÜR NORMUNG
CEN-CENELEC Management Centre: Rue de la Science 23, B-1040 Brussels
© 2022 CEN All rights of exploitation in any form and by any means reserved Ref. No. CEN/TS 17742:2022 E
worldwide for CEN national Members.
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Contents Page
European foreword . 3
Introduction . 4
1 Scope . 5
2 Normative references . 5
3 Terms and definitions . 5
4 General considerations . 10
5 Outside the laboratory . 11
5.1 Specimen collection . 11
5.1.1 General . 11
5.1.2 Information about the patient/specimen donor . 11
5.1.3 Selection of the venous whole blood collection tube by the laboratory . 12
5.1.4 Venous whole blood specimen collection from the patient/donor . 12
5.2 Specimen storage and transport . 13
5.2.1 General . 13
5.2.2 Storage and transport using blood collection tubes with stabilizers . 13
5.2.3 Storage and transport using blood collection tubes without stabilizers . 14
6 Inside the laboratory . 14
6.1 Specimen reception . 14
6.2 Storage requirements for blood specimens . 14
6.3 Plasma preparation . 15
6.4 Storage requirements for plasma samples . 15
6.5 Isolation of ccfRNA . 16
6.5.1 General . 16
6.5.2 Using a commercial ccfRNA isolation kit intended for diagnostic use . 16
6.5.3 Using a laboratory developed ccfRNA isolation procedure . 17
6.6 Quantity and quality assessment of isolated ccfRNA . 17
6.6.1 General . 17
6.6.2 Quantity assessment . 18
6.6.3 Quality assessment . 18
6.7 Storage of isolated ccfRNA . 18
Annex A (informative) Impact of pre-examination process steps on circulating cell free RNA
profiles in venous whole blood plasma . 20
Bibliography . 23
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European foreword
This document (CEN/TS 17742:2022) has been prepared by Technical Committee CEN/TC 140 “In vitro
diagnostic medical devices”, the secretariat of which is held by DIN.
Attention is drawn to the possibility that some of the elements of this document may be the subject of
patent rights. CEN shall not be held responsible for identifying any or all such patent rights.
Any feedback and questions on this document should be directed to the users’ national standards body.
A complete listing of these bodies can be found on the CEN website.
According to the CEN/CENELEC Internal Regulations, the national standards organisations of the
following countries are bound to announce this Technical Specification: Austria, Belgium, Bulgaria,
Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland,
Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Norway, Poland, Portugal, Republic of
North Macedonia, Romania, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland, Turkey and the United
Kingdom.
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Introduction
Molecular in vitro diagnostics has enabled a significant progress in medicine. Further progress is expected
by new technologies analysing profiles of nucleic acids, proteins, and metabolites in human tissues and
body fluids. However, the profiles of these molecules can change drastically during the pre-examination
process, including the specimen collection, transport, storage and processing.
Consequently, this makes the outcome from diagnostics or research unreliable or even impossible, as the
subsequent examination might not determine the real situation in the patient, but an artificial profile
generated during the pre-examination processes.
Besides circulating cell free DNA (ccfDNA), circulating tumour cells (CTCs) and other rare cells,
circulating cell free RNA (ccfRNA) represents another key component of liquid biopsies. Therefore, there
is a strongly increasing interest in emerging diagnostics and research in ccfRNA.
In blood, ccfRNA is composed of extracellular RNA present both in and outside of exosomes and other
extracellular vesicles. The pre-examination process described in this document results in total ccfRNA
isolated from blood plasma.
ccfRNA profiles and quantity can change significantly after blood collection, e.g. by release and/or uptake
of RNA containing extracellular vesicles by cells present in the blood specimen as well as by ccfRNA
degradation. Therefore, special measures have to be taken to secure good quality specimens for ccfRNA
examination.
Standardization of the entire workflow from specimen collection to the ccfRNA examination is therefore
needed. Studies have been undertaken to determine the important influencing factors. This document
draws upon such work to codify and standardize the steps of ccfRNA examination in what is referred to
as the pre-examination phase.
In this document, the following verbal forms are used:
— “shall” indicates a requirement;
— “should” indicates a recommendation;
— “may” indicates a permission;
— “can” indicates a possibility or a capability.
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1 Scope
This document specifies requirements and recommendations for the pre-examination phase of
circulating cell free RNA (ccfRNA) from venous whole blood specimens, including but not limited to the
collection, handling, storage, processing and documentation of venous whole blood specimens intended
for ccfRNA examination. This document covers specimens collected in venous whole blood collection
tubes.
The pre-examination process described in this document results in circulating cell free RNA isolated from
blood plasma without prior enrichment of exosomes and other extracellular vesicles.
This document is applicable to molecular in vitro diagnostic examinations performed by medical
laboratories. It is also intended to be used by laboratory customers, in vitro diagnostics developers and
manufacturers, biobanks, institutions and commercial organizations performing biomedical research,
and regulatory authorities.
Different dedicated measures need to be taken during the pre-examination phase for isolated RNA from
enriched exosomes and other extracellular vesicles enriched from venous whole blood and for cellular
RNA isolated from venous whole blood. These are not described in this document but are covered in
1
CEN/TS 17747, Molecular in vitro diagnostic examinations - Specifications for pre-examination processes
for exosomes and other extracellular vesicles in venous whole blood - Isolated DNA, RNA and proteins, and
in EN ISO 20186-1, Molecular in vitro diagnostic examinations - Specifications for pre-examination
processes for venous whole blood - Part 1: Isolated cellular RNA.
NOTE International, national or regional regulations or requirements can also apply to specific topics covered
in this document.
2 Normative references
The following documents are referred to in the text in such a way that some or all of their content
constitutes requirements of this document. For dated references, only the edition cited applies. For
undated references, the latest edition of the referenced document (including any amendments) applies.
EN ISO 15189, Medical laboratories - Requirements for quality and competence (ISO 15189)
ISO 15190, Medical laboratories — Requirements for safety
3 Terms and definitions
For the purposes of this document, the terms and definitions given in EN ISO 15189 and the following
apply.
ISO and IEC maintain terminological databases for use in standardization at the following addresses:
— ISO Online browsing platform: available at https://www.iso.org/obp
— IEC Electropedia: available at https://www.electropedia.org/
1
Under preparation. Stage at the time of publication: FprCEN/TS 17747.
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3.1
aliquot
portion of a larger amount of homogenous material, assumed to be taken with negligible sampling error
Note 1 to entry: The term is usually applied to fluids. Tissues are heterogeneous and therefore cannot be
aliquoted.
Note 2 to entry: The definition is derived from the Compendium of Chemical Terminology Gold Book.
International Union of Pure and Applied Chemistry. Version 2.3.3., 2014; the PAC, 1990,62,1193 (Nomenclature for
sampling in analytical chemistry (Recommendations 1990)) p. 1206; and the PAC 1990, 62, 2167 (Glossary of
atmospheric chemistry terms (Recommendations 1990)) p. 2173.
3.2
ambient temperature
unregulated temperature of the surrounding air
[SOURCE: EN ISO 20166-1:2018, 3.2]
3.3
analyte
component represented in the name of a measurable quantity
[SOURCE: ISO 17511:2020, 3.2, modified — Deleted Example.]
3.4
backflow
flow of a liquid opposite to the usual or desired direction
3.5
blood collection set
intravenous device specialized for venipuncture consisting of a stainless steel bevelled needle and tube
(tubing) with attached plastic wings and fitting connector
Note 1 to entry: The connector attaches to an additional blood collection device, e.g. a blood collection tube.
3.6
blood collection tube
tube used for blood collection, usually with a vacuum which forces blood from the vein through the needle
into the tube
3.7
circulating cell free DNA
ccfDNA
extracellular human DNA present in blood and plasma
Note 1 to entry: ccfDNA includes DNA present in extracellular vesicles such as exosomes.
3.8
circulating cell free RNA
ccfRNA
extracellular human RNA present in blood and plasma
Note 1 to entry: ccfRNA includes RNA present in extracellular vesicles such as exosomes.
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3.9
circulating cell free RNA profile
ccfRNA profile
amount of different ccfRNA molecules, present in blood and plasma that can be measured in the absence
of any losses, inhibition and interference
3.10
closed system
non-modifiable system provided by the vendor including all necessary components for the examination
(i.e. hardware, software, procedures and reagents)
3.11
deoxyribonucleic acid
DNA
polymer of deoxyribonucleotides occurring in a double-stranded (dsDNA) or single-stranded (ssDNA)
form
[SOURCE: EN ISO 22174:2005, 3.1.2]
3.12
deoxyribonuclease
DNase
enzyme that catalyzes the degradation of DNA into smaller components
3.13
examination
analytical test
set of operations having the object of determining the value or characteristics of a property
Note 1 to entry: Processes (i.e. set of operations) that start with the isolated analyte and include all kinds of
parameter testing or chemical manipulation for quantitative or qualitative examination.
[SOURCE: EN ISO 15189:2012, 3.7, modified — Term and definition are used here without the original
notes; an additional preferred term was added.]
3.14
examination manufacturer
analytical test manufacturer
entity that manufactures and/or produces a specific analytical test
3.15
examination performance
analytical test performance
analytical performance
accuracy, precision, and sensitivity of a test to measure the analyte of interest
Note 1 to entry: Other test performance characteristics such as robustness, repeatability can apply as well.
[SOURCE: EN ISO 20184-1:2018, 3.4]
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3.16
extracellular vesicle
EV
particle naturally released from the cell that is delimited by a lipid bilayer and cannot replicate, i.e. does
not contain a functional nucleus
EXAMPLE Exosomes, endosomes, oncosomes, apoptotic bodies
[SOURCE: [13]]
3.17
interfering substance
endogenous or exogenous substance in clinical specimens/samples that can alter an examination result
Note 1 to entry: Examples of endogenous substances are blood components and acidic polysaccharides.
Note 2 to entry: Examples of exogenous substances are talc and anticoagulant.
3.18
laboratory developed procedure
modified commercially available in vitro diagnostic device or fully in house developed procedure
3.19
needle holder
barrel used in routine venepuncture procedures to hold the blood collection tube in place and to protect
the phlebotomist from direct contact with blood
3.20
pre-examination process
preanalytical phase
preanalytical workflow
pre-examination phase
process that starts, in chronological order, from the clinician’s request and includes the examination
request, preparation and identification of the patient, collection of the primary sample(s), transportation
to and within the medical laboratory, storage, isolation of analytes, and ends when the analytical
examination begins
Note 1 to entry: The pre-examination phase includes preparative processes, e.g. RNA isolation procedures, which
influence the outcome of the intended examination.
[SOURCE: EN ISO 15189:2012, 3.15, modified — An additional term was added and more detail was
included.]
3.21
primary sample
specimen
discrete portion of a body fluid, breath, hair or tissue taken for examination, study or analysis of one or
more quantities or properties assumed to apply for the whole
[SOURCE: EN ISO 15189:2012, 3.16, modified — The term and definition are used here without the
original notes.]
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3.22
ribonucleic acid
RNA
polymer of ribonucleotides occurring in a double-stranded or single-stranded form
[SOURCE: EN ISO 22174:2005, 3.1.3]
3.23
ribonuclease
RNase
enzyme that catalyses the degradation of RNA into smaller components
3.24
room temperature
temperature in the range of 18 °C to 25 °C
Note 1 to entry: Local or national regulations can have different definitions.
[SOURCE: EN ISO 20166-1:2018, 3.22]
3.25
sample
one or more parts taken from a primary sample
[SOURCE: EN ISO 15189:2012, 3.24, modified — Example has been removed.]
3.26
stability
ability of a sample material, when stored under specified conditions, to maintain a stated property value
within specified limits for a specified period of time
[SOURCE: ISO Guide 30:2015, 2.1.15, modified — The phrase “reference material” has been replaced by
“sample material”.]
3.27
storage
prolonged interruption of the pre-analytical workflow of a sample or analyte respectively, or of their
derivatives, under appropriate conditions in order to preserve their properties
Note 1 to entry: Long-term storage typically occurs in laboratory archives or in biobanks.
[SOURCE: EN ISO 20184-1:2018, 3.21, modified — Example has been removed.]
3.28
validation
confirmation, through the provision of objective evidence, that the requirements for a specific intended
use or application have been fulfilled
Note 1 to entry: The term “validated” is used to designate the corresponding status.
[SOURCE: ISO 9000:2015, 3.8.13, modified — Note 1 and Note 3 have been omitted.]
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3.29
venous whole blood
blood collected after directly puncturing a vein, usually with a needle and syringe, or other collection
device
3.30
verification
confirmation, through the provision of objective evidence, that specified requirements have been fulfilled
Note 1 to entry: The term “verified” is used to designate the corresponding status.
Note 2 to entry: Confirmation can comprise activities such as:
— performing alternative calculations;
— comparing a new design specification with a similar proven design specification;
— undertaking tests and demonstrations;
— reviewing documents prior to issue.
[SOURCE: ISO 9000:2015, 3.8.12, modified — Note 1 and Note 2 have been omitted.]
3.31
workflow
series of activities necessary to complete a task
[SOURCE: EN ISO 20166-1:2018, 3.30]
4 General considerations
For general statements on medical laboratory quality management systems and in particular on
specimen collection, reception and handling (including avoidance of cross contaminations) see
EN ISO 15189, EN ISO/IEC 17020 or EN ISO/IEC 17025. ISO/TS 20658 and EN ISO 20387 (for
biobanking) can also apply. The requirements on laboratory equipment, reagents, and consumables
according to EN ISO 15189 shall be followed; EN ISO/IEC 17020 and EN ISO/IEC 17025 can also apply.
All steps of the pre-examination, examination and post-examination processes (i.e. the entire workflow)
can influence the diagnosis or research study results. Thus, this entire workflow shall be specified,
verified and validated during the development of the examination, including the development of in vitro
diagnostic (IVD) medical devices. This includes specifically all pre-examination process steps such as the
examination request, preparation and identification of the patient, collection of the primary sample(s),
transport to and within the medical laboratory, storage and isolation of analytes.
ccfRNA profiles can consist of different species such as mRNA, miRNA and other non-coding RNA [14][15]
and can change significantly after blood collection [16]. The post-collection release of cellular RNA from
cells in blood can change the ccfRNA profile significantly (see Annex A). Additional post-collection effects
can also occur, e.g. ccfRNA degradation. All these post-collection changes can vary individually in
specimens from different donors or patients, and they can also depend on pathophysiological conditions
[17][18]. This can impact the validity and reliability of the examination results [19].
During the design and development of a ccfRNA based examination, a risk assessment shall be performed
(see also EN ISO 14971). Mitigation measures for eliminating or reducing identified risks shall be
established where required for ensuring the performance of the examination. It shall especially be
investigated and ensured that the ccfRNA profile(s) intended to be analysed is/are not compromised in
a manner impacting the examination performance. This includes investigations on whether and/or how
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the ccfRNA profile intended to be examined changes during collection, storage, transport and ccfRNA
isolation. This can be done, e.g. by applying the intended examination to specimens/samples which
underwent time course studies reflecting the individual pre-examination process steps such as transport
and storage and by implementing measures to prevent or reduce impacts by the identified pre-analytical
variables, e.g. by using blood collection tubes with stabilizers.
NOTE A time course study involves repeated observations of the same variables at specific intervals over a
relevant time period (e.g. time 0, 12 h, 24 h, 36 h, 48 h). This reflects any knowledge on the stability of the analyte(s)
of interest. Typically, this involves multiple aliquots from the same donor taken from the same blood draw repeated
for several donors. See [19] as an example.
During the whole pre-examination process, precautions shall be taken to avoid cross contamination
between different specimens/samples (e.g. by using single-use material whenever feasible or
appropriate cleaning procedures between processing of different specimens/samples) and to avoid
mixing up of specimens/samples.
Safety instructions for the whole pre-examination process shall be in place and followed. Safety
regulations on specimen/sample transport and handling shall be considered (see EN ISO 15189,
ISO 15190 and ISO/TS 20658). If transport is required over public areas, corresponding regulations or
laws for packaging and transport apply (e.g. International Air Transport Association (IATA) for air
transport).
The manufacturer's material safety data sheet should be considered before first use of any potentially
hazardous material (e.g. chemicals in stabilizers).
For all pre-examination steps, the examination manufacturer's instructions shall be followed.
Where, for justified reasons (e.g. unmet patient needs), a commercial product is not used in accordance
with the manufacturer's instructions, responsibility for its verification, validation, use and performance
lies with the laboratory.
5 Outside the laboratory
5.1 Specimen collection
5.1.1 General
For the collection of the blood specimen, the requirements for the intended molecular examination (e.g.
type of blood collection tube, collection procedure; see also Clause 6) shall be considered.
See also EN ISO 15189.
5.1.2 Information about the patient/specimen donor
The documentation shall include the identity of the patient/specimen donor, which can be in the form of
a code.
The documentation should include, but is not limited to:
a) the relevant health status of the specimen donor or patient (e.g. healthy, disease type, concomitant
disease, demographics [e.g. age and gender]);
NOTE 1 In particular, e.g. cancer has been reported to affect ccfRNA quantity and profile in various malignancies
[17][18][20][21][22][23][24][25]and a wide range of disorders, ranging from acute myocardial infarction to
congestive, heart failure and drug-induced liver injury [26][27][28], while during pregnancy, fetal ccfRNA was
detected in maternal blood [29].
b) the information about medical treatment and special treatment prior to blood collection (e.g.
anaesthetics, medications, fasting status);
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c) the information on relevant lifestyle parameters, such as physical exercise [30];
NOTE 2 Physical exercise can alter the ccfRNA profile compared to a baseline condition [30].
d) the type and purpose of the proposed examination requested;
e) the appropriate consent from the patient/specimen donor.
See also EN ISO 15189.
5.1.3 Selection of the venous whole blood collection tube by the laboratory
The ccfRNA profile can be influenced by inadequate venous whole blood collection procedures and
inappropriate storage/transport conditions (see Annex A), plasma separation [31][32] as well as by
ccfRNA isolation procedures [19]. Venous whole blood shall therefore be collected in appropriate blood
collection tubes.
The ccfRNA examination manufacturer instructions should contain specifications on the blood collection
tube(s) to be used. Where the examination manufacturer specifies usage of dedicated blood collection
tube(s), these shall be used.
Where the examination manufacturer does not provide such specifications (e.g. due to (a) former less
stringent legal framework(s)), the blood collection tube shall be specified, verified and documented by
the laboratory.
Blood should be collected in venous whole blood collection tubes containing ccfRNA profile stabilizers
for preventing post-collection ccfRNA profile changes (see Clause 4) (see Annex A). The tubes' catalogue
and lot number should be documented.
Blood collection tubes not containing any ccfRNA profile stabilizers should be used only if specified by
the examination manufacturer's instructions. In these cases, ethylenediamine tetraacetic acid (EDTA)
blood collecti
...
SLOVENSKI STANDARD
kSIST-TS FprCEN/TS 17742:2021
01-december-2021
Molekularne diagnostične preiskave in vitro - Specifikacije za predpreiskovalne
procese za vensko polno kri - Iz plazme izolirana cirkulirajoča brezcelična RNK
Molecular in vitro diagnostic examinations - Specifications for pre-examination processes
for venous whole blood - Isolated circulating cell free RNA from plasma
Molekularanalytische in-vitro-diagnostische Verfahren - Spezifikationen für
präanalytische Prozesse für venöse Vollblutproben - Isolierte zirkulierende zellfreie RNA
aus Plasma
Ta slovenski standard je istoveten z: FprCEN/TS 17742
ICS:
11.100.10 Diagnostični preskusni In vitro diagnostic test
sistemi in vitro systems
kSIST-TS FprCEN/TS 17742:2021 en,fr,de
2003-01.Slovenski inštitut za standardizacijo. Razmnoževanje celote ali delov tega standarda ni dovoljeno.
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kSIST-TS FprCEN/TS 17742:2021
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kSIST-TS FprCEN/TS 17742:2021
FINAL DRAFT
TECHNICAL SPECIFICATION
FprCEN/TS 17742
SPÉCIFICATION TECHNIQUE
TECHNISCHE SPEZIFIKATION
October 2021
ICS 11.100.10
English Version
Molecular in vitro diagnostic examinations - Specifications
for pre-examination processes for venous whole blood -
Isolated circulating cell free RNA from plasma
Molekularanalytische in-vitro-diagnostische Verfahren
- Spezifikationen für präanalytische Prozesse für
venöse Vollblutproben - Isolierte zirkulierende
zellfreie RNA aus Plasma
This draft Technical Specification is submitted to CEN members for Vote. It has been drawn up by the Technical Committee
CEN/TC 140.
CEN members are the national standards bodies of Austria, Belgium, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia,
Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Norway,
Poland, Portugal, Republic of North Macedonia, Romania, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland, Turkey and
United Kingdom.
Recipients of this draft are invited to submit, with their comments, notification of any relevant patent rights of which they are
aware and to provide supporting documentation.
Warning : This document is not a Technical Specification. It is distributed for review and comments. It is subject to change
without notice and shall not be referred to as a Technical Specification.
EUROPEAN COMMITTEE FOR STANDARDIZATION
COMITÉ EUROPÉEN DE NORMALISATION
EUROPÄISCHES KOMITEE FÜR NORMUNG
CEN-CENELEC Management Centre: Rue de la Science 23, B-1040 Brussels
© 2021 CEN All rights of exploitation in any form and by any means reserved Ref. No. FprCEN/TS 17742:2021 E
worldwide for CEN national Members.
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Contents
Page
European foreword . 3
Introduction . 4
1 Scope . 5
2 Normative references . 5
3 Terms and definitions . 5
4 General considerations . 10
5 Outside the laboratory . 11
5.1 Specimen collection . 11
5.1.1 General . 11
5.1.2 Information about the patient/specimen donor . 11
5.1.3 Selection of the venous whole blood collection tube by the laboratory . 12
5.1.4 Venous whole blood specimen collection from the patient/donor . 12
5.2 Specimen storage and transport . 13
5.2.1 General . 13
5.2.2 Storage and transport using blood collection tubes with stabilizers . 13
5.2.3 Storage and transport using blood collection tubes without stabilizers . 14
6 Inside the laboratory . 14
6.1 Specimen reception . 14
6.2 Storage requirements for blood specimens . 14
6.3 Plasma preparation . 14
6.4 Storage requirements for plasma samples . 15
6.5 Isolation of ccfRNA . 16
6.5.1 General . 16
6.5.2 Using a commercial ccfRNA isolation kit intended for diagnostic use . 16
6.5.3 Using a laboratory developed ccfRNA isolation procedure . 17
6.6 Quantity and quality assessment of isolated ccfRNA . 17
6.6.1 General . 17
6.6.2 Quantity assessment . 18
6.6.3 Quality assessment . 18
6.7 Storage of isolated ccfRNA . 18
Annex A (informative) Impact of pre-examination process steps on circulating cell free RNA
profiles in venous whole blood plasma . 20
Bibliography . 23
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European foreword
This document (FprCEN/TS 17742:2021) has been prepared by Technical Committee CEN/TC 140 “In
vitro diagnostic medical devices”, the secretariat of which is held by DIN.
This document is currently submitted to the Vote on TS.
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Introduction
Molecular in vitro diagnostics has enabled a significant progress in medicine. Further progress is expected
by new technologies analysing profiles of nucleic acids, proteins, and metabolites in human tissues and
body fluids. However, the profiles of these molecules can change drastically during the pre-examination
process, including the specimen collection, transport, storage and processing.
Consequently, this makes the outcome from diagnostics or research unreliable or even impossible, as the
subsequent examination might not determine the real situation in the patient, but an artificial profile
generated during the pre-examination processes.
Besides cell free circulating nucleic acids, circulating tumour cells (CTCs) and other rare cells, cell free
circulating RNA (ccfRNA) represents another key component of liquid biopsies. Therefore, there is a
strongly increasing interest in emerging diagnostics and research in ccfRNA.
In blood, ccfRNA is composed of extracellular RNA present both in and outside of exosomes and other
extracellular vesicles. The pre-examination process described in this document results in total ccfRNA
isolated from blood plasma.
ccfRNA profiles and quantity can change significantly after blood collection, e.g. by release and/or uptake
of RNA containing extracellular vesicles by cells present in the blood specimen as well as by ccfRNA
degradation. Therefore, special measures have to be taken to secure good quality specimens for ccfRNA
examination.
Standardization of the entire workflow from specimen collection to the ccfRNA examination is therefore
needed. Studies have been undertaken to determine the important influencing factors. This document
draws upon such work to codify and standardize the steps of ccfRNA examination in what is referred to
as the pre-examination phase.
In this document, the following verbal forms are used:
— “shall” indicates a requirement;
— “should” indicates a recommendation;
— “may” indicates a permission;
— “can” indicates a possibility or a capability.
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1 Scope
This document specifies requirements and recommendations for the pre-examination phase of
circulating cell free RNA (ccfRNA) from venous whole blood specimens, including but not limited to the
collection, handling, storage, processing and documentation of venous whole blood specimens intended
for ccfRNA examination. This document covers specimens collected in venous whole blood collection
tubes.
The pre-examination process described in this document results in circulating cell free RNA isolated from
blood plasma without prior enrichment of exosomes and other extracellular vesicles.
This document is applicable to molecular in vitro diagnostic examinations performed by medical
laboratories. It is also intended to be used by laboratory customers, in vitro diagnostics developers and
manufacturers, biobanks, institutions and commercial organizations performing biomedical research,
and regulatory authorities.
Different dedicated measures need to be taken during the pre-examination phase for isolated RNA from
enriched exosomes and other extracellular vesicles enriched from venous whole blood and for cellular
RNA isolated from venous whole blood. These are not described in this document but are covered in
CEN/TS 17747, Molecular in vitro diagnostic examinations — Specifications for pre-examination processes
for exosomes and other extracellular vesicles in venous whole blood — Isolated DNA, RNA and proteins, and
in EN ISO 20186-1, Molecular in vitro diagnostic examinations — Specifications for pre-examination
processes for venous whole blood — Part 1: Isolated cellular RNA.
NOTE International, national or regional regulations or requirements can also apply to specific topics covered
in this document.
2 Normative references
The following documents are referred to in the text in such a way that some or all of their content
constitutes requirements of this document. For dated references, only the edition cited applies. For
undated references, the latest edition of the referenced document (including any amendments) applies.
EN ISO 15189, Medical laboratories - Requirements for quality and competence (ISO 15189)
EN ISO 15190, Medical laboratories — Requirements for safety (ISO 15190)
3 Terms and definitions
For the purposes of this document, the terms and definitions given in EN ISO 15189 and the following
apply.
ISO and IEC maintain terminological databases for use in standardization at the following addresses:
— ISO Online browsing platform: available at https://www.iso.org/obp
— IEC Electropedia: available at https://www.electropedia.org/
3.1
aliquot
portion of a larger amount of homogenous material, assumed to be taken with negligible sampling error
Note 1 to entry: The term is usually applied to fluids. Tissues are heterogeneous and therefore cannot be
aliquoted.
Note 2 to entry: The definition is derived from the Compendium of Chemical Terminology Gold Book.
International Union of Pure and Applied Chemistry. Version 2.3.3., 2014; the PAC, 1990,62,1193 (Nomenclature for
sampling in analytical chemistry (Recommendations 1990)) p. 1206; and the PAC 1990, 62, 2167 (Glossary of
atmospheric chemistry terms (Recommendations 1990)) p. 2173.
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3.2
ambient temperature
unregulated temperature of the surrounding air
[SOURCE: EN ISO 20166-1:2018, 3.2]
3.3
analyte
component represented in the name of a measurable quantity
[SOURCE: EN ISO 17511:2020, 3.2, modified — Deleted Example.]
3.4
backflow
flow of a liquid opposite to the usual or desired direction
3.5
blood collection set
intravenous device specialized for venipuncture consisting of a stainless steel beveled needle and tube
(tubing) with attached plastic wings and fitting connector
Note 1 to entry: The connector attaches to an additional blood collection device, e.g. a blood collection tube.
3.6
blood collection tube
tube used for blood collection, usually with a vacuum which forces blood from the vein through the needle
into the tube
3.7
circulating cell free DNA
ccfDNA
extracellular human DNA present in blood and plasma
Note 1 to entry: ccfDNA includes DNA present in extracellular vesicles such as exosomes.
3.8
circulating cell free RNA
ccfRNA
extracellular human RNA present in blood and plasma
Note 1 to entry: ccfRNA includes RNA present in extracellular vesicles such as exosomes.
3.9
circulating cell free RNA profile
ccfRNA profile
amount of different ccfRNA molecules, present in blood and plasma that can be measured in the absence
of any losses, inhibition and interference
3.10
closed system
non-modifiable system provided by the vendor including all necessary components for the examination
(i.e. hardware, software, procedures and reagents)
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3.11
deoxyribonucleic acid
DNA
polymer of deoxyribonucleotides occurring in a double-stranded (dsDNA) or single-stranded (ssDNA)
form
[SOURCE: EN ISO 22174:2005, 3.1.2]
3.12
deoxyribonuclease
DNase
enzyme that catalyzes the degradation of DNA into smaller components
3.13
examination
analytical test
set of operations having the object of determining the value or characteristics of a property
Note 1 to entry: Processes (i.e. set of operations) that start with the isolated analyte and include all kinds of
parameter testing or chemical manipulation for quantitative or qualitative examination.
[SOURCE: EN ISO 15189:2012, 3.7, modified — Term and definition are used here without the original
notes; an additional preferred term was added.]
3.14
examination manufacturer
analytical test manufacturer
entity that manufactures and/or produces a specific analytical test
3.15
examination performance
analytical test performance
analytical performance
accuracy, precision, and sensitivity of a test to measure the analyte of interest
Note 1 to entry: Other test performance characteristics such as robustness, repeatability can apply as well.
[SOURCE: EN ISO 20184-1:2018, 3.4]
3.16
extracellular vesicle
EV
particle naturally released from the cell that is delimited by a lipid bilayer and cannot replicate, i.e. does
not contain a functional nucleus
EXAMPLE Exosomes, endosomes, oncosomes, apoptotic bodies
[SOURCE: [13]]
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3.17
interfering substance
endogenous or exogenous substance in clinical specimens/samples that can alter an examination result
Note 1 to entry: Examples of endogenous substances are blood components and acidic polysaccharides.
Note 2 to entry: Examples of exogenous substances are talc and anticoagulant.
3.18
laboratory developed procedure
modified commercially available in vitro diagnostic device or fully in house developed procedure
3.19
needle holder
barrel used in routine venepuncture procedures to hold the blood collection tube in place and to protect
the phlebotomist from direct contact with blood
3.20
pre-examination process
preanalytical phase
preanalytical workflow
pre-examination phase
process that starts, in chronological order, from the clinician’s request and includes the examination
request, preparation and identification of the patient, collection of the primary sample(s), transportation
to and within the medical laboratory, storage, isolation of analytes, and ends when the analytical
examination begins
Note 1 to entry: The pre-examination phase includes preparative processes, e.g. RNA isolation procedures, which
influence the outcome of the intended examination.
[SOURCE: EN ISO 15189:2012, 3.15, modified — An additional term was added and more detail was
included.]
3.21
primary sample
specimen
discrete portion of a body fluid, breath, hair or tissue taken for examination, study or analysis of one or
more quantities or properties assumed to apply for the whole
[SOURCE: EN ISO 15189:2012, 3.16, modified — The term and definition are used here without the
original notes.]
3.22
ribonucleic acid
RNA
polymer of ribonucleotides occurring in a double-stranded or single-stranded form
[SOURCE: EN ISO 22174:2005, 3.1.3]
3.23
ribonuclease
RNase
enzyme that catalyses the degradation of RNA into smaller components
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3.24
room temperature
temperature in the range of 18 °C to 25 °C
Note 1 to entry: Local or national regulations can have different definitions.
[SOURCE: EN ISO 20166-1:2018, 3.22]
3.25
sample
one or more parts taken from a primary sample
[SOURCE: EN ISO 15189:2012, 3.24, modified — Example has been removed.]
3.26
stability
ability of a sample material, when stored under specified conditions, to maintain a stated property value
within specified limits for a specified period of time
[SOURCE: ISO Guide 30:2015, 2.1.15, modified — The phrase “reference material” has been replaced by
“sample material”.]
3.27
storage
prolonged interruption of the pre-analytical workflow of a sample or analyte respectively, or of their
derivatives, under appropriate conditions in order to preserve their properties
Note 1 to entry: Long-term storage typically occurs in laboratory archives or in biobanks.
[SOURCE: EN ISO 20184-1:20172018, 3.21, modified — Example has been removed.]
3.28
validation
confirmation, through the provision of objective evidence, that the requirements for a specific intended
use or application have been fulfilled
Note 1 to entry: The term “validated” is used to designate the corresponding status.
[SOURCE: ISO 9000:2015, 3.8.13, modified — Note 1 and Note 3 have been omitted.]
3.29
venous whole blood
blood collected after directly puncturing a vein, usually with a needle and syringe, or other collection
device
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3.30
verification
confirmation, through the provision of objective evidence, that specified requirements have been fulfilled
Note 1 to entry: The term “verified” is used to designate the corresponding status.
Note 2 to entry: Confirmation can comprise activities such as:
— performing alternative calculations;
— comparing a new design specification with a similar proven design specification;
— undertaking tests and demonstrations;
— reviewing documents prior to issue.
[SOURCE: ISO 9000:2015, 3.8.12, modified — Note 1 and Note 2 have been omitted.]
3.31
workflow
series of activities necessary to complete a task
[SOURCE: EN ISO 20166-1:2018, 3.30]
4 General considerations
For general statements on medical laboratory quality management systems and in particular on
specimen collection, reception and handling (including avoidance of cross contaminations) see
EN ISO 15189, EN ISO/IEC 17020 or EN ISO/IEC 17025. ISO/TS 20658 and EN ISO 20387 (for
biobanking) can also apply. The requirements on laboratory equipment, reagents, and consumables
according to EN ISO 15189 shall be followed; EN ISO/IEC 17020 and EN ISO/IEC 17025 can also apply.
All steps of the pre-examination, examination and post-examination processes (i.e. the entire workflow)
can influence the diagnosis or research study results. Thus, this entire workflow shall be specified,
verified and validated during the development of the examination, including the development of in vitro
diagnostic (IVD) medical devices. This includes specifically all pre-examination process steps such as the
examination request, preparation and identification of the patient, collection of the primary sample(s),
transport to and within the medical laboratory, storage and isolation of analytes.
ccfRNA profiles can consist of different species such as mRNA, miRNA and other non-coding RNA [14][15]
and can change significantly after blood collection [16]. The post-collection release of cellular RNA from
cells in blood can change the ccfRNA profile significantly (see A.1). Additional post-collection effects can
also occur, e.g. ccfRNA degradation. All these post-collection changes can vary individually in specimens
from different donors or patients, and they can also depend on pathophysiological conditions [17][18].
This can impact the validity and reliability of the examination results [19].
During the design and development of a ccfRNA based examination, a risk assessment shall be performed
(see also EN ISO 14971). Mitigation measures for eliminating or reducing identified risks shall be
established where required for ensuring the performance of the examination. It shall especially be
investigated and ensured that the ccfRNA profile(s) intended to be analysed is/are not compromised in
a manner impacting the examination performance. This includes investigations on whether and/or how
the ccfRNA profile intended to be examined changes during collection, storage, transport and ccfRNA
isolation. This can be done, e.g. by applying the intended examination to specimens/samples which
underwent time course studies reflecting the individual pre-examination process steps such as transport
and storage and by implementing measures to prevent or reduce impacts by the identified pre-analytical
variables, e.g. by using blood collection tubes with stabilizers.
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NOTE A time course study involves repeated observations of the same variables at specific intervals over a
relevant time period (e.g. time 0, 12 h, 24 h, 36 h, 48 h). This reflects any knowledge on the stability of the analyte(s)
of interest. Typically, this involves multiple aliquots from the same donor taken from the same blood draw repeated
for several donors. See [19] as an example.
During the whole pre-examination process, precautions shall be taken to avoid cross contamination
between different specimens/samples (e.g. by using single-use material whenever feasible or
appropriate cleaning procedures between processing of different specimens/samples) and to avoid
mixing up of specimens/samples .
Safety instructions for the whole pre-examination process shall be in place and followed. Safety
regulations on specimen/sample transport and handling shall be considered (see EN ISO 15189,
EN ISO 15190 and ISO/TS 20658). If transport is required over public areas, corresponding regulations
or laws for packaging and transport apply (e.g. International Air Transport Association (IATA) for air
transport).
The manufacturer's material safety data sheet should be considered before first use of any potentially
hazardous material (e.g. chemicals in stabilizers).
For all pre-examination steps, the examination manufacturer's instructions shall be followed, if provided.
Where, for justified reasons (e.g. unmet patient needs), a commercial product is not used in accordance
with the manufacturer's instructions, responsibility for its verification, validation, use and performance
lies with the laboratory.
5 Outside the laboratory
5.1 Specimen collection
5.1.1 General
For the collection of the blood specimen, the requirements for the intended molecular examination (e.g.
type of blood collection tube, collection procedure; see also Clause 6) shall be considered.
See also EN ISO 15189.
5.1.2 Information about the patient/specimen donor
The documentation shall include the identity of the patient/specimen donor, which can be in the form of
a code.
The documentation should include, but is not limited to:
a) the relevant health status of the specimen donor or patient (e.g. healthy, disease type, concomitant
disease, demographics [e.g. age and gender]);
NOTE 1 In particular, e.g. cancer has been reported to affect ccfRNA quantity and profile in various malignancies
[17][18][20][21][22][23][24][25]and a wide range of disorders, ranging from acute myocardial infarction to
congestive, heart failure and drug-induced liver injury [26][27][28], while during pregnancy, fetal ccfRNA was
detected in maternal blood [29].
b) the information about medical treatment and special treatment prior to blood collection (e.g.
anaesthetics, medications, fasting status);
c) the information on relevant lifestyle parameters, such as physical exercise [30];
NOTE 2 Physical exercise can alter the ccfRNA profile compared to a baseline condition [30].
d) the type and purpose of the proposed examination requested;
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e) the appropriate consent from the patient/specimen donor.
See also EN ISO 15189.
5.1.3 Selection of the venous whole blood collection tube by the laboratory
The ccfRNA profile can be influenced by inadequate venous whole blood collection procedures and
inappropriate storage/transport conditions (see Annex A.1), plasma separation [31][32] as well as by
ccfRNA isolation procedures [19]. Venous whole blood shall therefore be collected in appropriate blood
collection tubes.
The ccfRNA examination manufacturer instructions should contain specifications on the blood collection
tube(s) to be used. Where the examination manufacturer specifies usage of dedicated blood collection
tube(s), these shall be used.
Where the examination manufacturer does not provide such specifications (e.g. due to (a) former less
stringent legal framework(s)), the blood collection tube shall be specified, verified and documented by
the laboratory.
Blood should be collected in venous whole blood collection tubes containing ccfRNA profile stabilizers
for preventing post-collection ccfRNA profile changes (see Clause 4) (see A.1). The tubes' catalogue and
lot number should be documented.
Blood collection tubes not containing any ccfRNA profile stabilizers should be used only if specified by
the examination manufacturer's instructions. In these cases, ethylenediamine tetraacetic acid (EDTA)
blood collection tubes should be used in preference to other collection tubes [33], although EDTA does
not prevent changes of ccfRNA profiles, but prevents clotting [16]. The examination manufacturer's
specifications shall be considered for further details.
In case of specimens for long-term storage in a biobank, it is usually not known which specific ccfRNA
profile will be examined after the long-term storage. To allow a broad future usage of specimen, blood
collection tubes with ccfRNA stabilizers should therefore be used for biobanking. Blood collected in tubes
without stabilizers in biobanks could be used for a specific examination, if verified that there is no impact
on the validity and reliability of this examination.
RNA released from cells in blood during the clotting process in serum tubes may change native ccfRNA
profiles, as previously demonstrated for blood ccfDNA profiles [34]. For this reason, serum tubes should
not be used unless verified and validated for the intended examination.
5.1.4 Venous whole blood specimen collection from the patient/donor
The identity of the person collecting the specimen shall be documented. This can be done, e.g. in form of
the name or a code.
...
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