College of American Pathologists Laboratory Accreditation Program. AP for Histotechs and Secretaries. Learning Objectives

Transcription

1 College of American Pathologists AP for Histotechs and Secretaries Francis E. Sharkey, M.D., FCAP University of Texas Health Science Center - San Antonio February 20th, 2008 Copyright 2008 College of American Pathologists (CAP). All rights are reserved. Participants are permitted to duplicate the materials for educational use only within their own institution. These materials may not be used for 1 commercial purposes or altered in any way. Learning Objectives As a result of participating in this activity, you will be able to: Recognize problems that may arise in the grossing room Identify critical technical parameters that affect the sensitivity, specificity and precision of immunohistochemical stains Develop procedures that improve the quality of Surgical Pathology reports 2 Name That Deficiency! Ground Rules Question-and-answer type of session More than one answer may be correct No peeking ahead! Keeping score is encouraged Speaker will provide: Discussion of pertinent issue(s) An answer to the question 3 1

2 Question #1 How often should formaldehyde vapor concentrations be checked? A. Monthly B. Yearly C. When new personnel are hired D. After ventilation maintenance E. Whenever staff complain 4 Formaldehyde Monitoring (ANP.08216) Monitor in all areas used Preferably when exposure greatest May discontinue monitoring if two consecutive samples taken at least 7 days apart meet OSHA requirements Monitor xylene initially; no requirement for periodic monitoring 5 Formaldehyde Monitoring (ANP.08216) If initial monitoring OK, must recheck if: Change in production, equipment, process, personnel, or control measures that may result in any new or additional exposure Any report of conditions that may be related to formaldehyde exposure Must monitor exposure of any person reporting respiratory or dermal irritation 6 2

3 Question #2 How often should the performance of nonpathologists who perform gross tissue examinations be evaluated? A. Daily B. Weekly C. Monthly D. Yearly E. Never 7 Non-Pathologist Tissue Exams Two levels of tissue examination Processing: Limited to description, inking and cutting of specimen, and submission of the entire specimen to histology. Grossing: Requires judgment and knowledge of anatomy, and dissection and selection of tissue samples. Specimen description is not necessarily standardized. Qualified for high-complexity testing. 8 Non-Pathologist Tissue Exams Extent of activities must be defined Nature of pathologist supervision defined Evaluated by pathologist periodically Periodic = at defined intervals Must be defined in lab policy ANP

4 True or False? Question #3 A procedure for safe handling of specimens with radioactive materials is unnecessary if the laboratory has never received any such specimens. 10 Radioactive Specimens (ANP.11275) Procedure requirements: Need input of radiation safety officer Compatible with local/state regulations Distinguish between specimens with low and high radioactivity levels; examples: Low - sentinel lymph node High - implant (cervix, prostate) Storage before grossing permissible 11 Question #4 How often should a cryostat be defrosted and decontaminated if it is used daily? A. Daily B. Weekly C. Monthly D. Yearly E. If exposed to infectious organisms 12 4

5 Decontamination of Cryostat (ANP.12087) Is there a documented procedure for the routine decontamination of the cryostat at defined intervals, and are decontamination records evident? Note adds: weekly for instruments used daily. Daily cleanup of shavings with 70% alcohol may also be performed 13 Question #5 Immunohistochemistry: Which of the following may be a cause of non-specific staining in the negative tissue control? A. Excessive antibody concentration B. Excessive epitope retrieval C. High endogenous biotin D. Length of fixation E. Type of fixative used 14 Formaldehyde Fixation Fixes proteins by linking them together via long polymerized chains Penetrates tissue at ~1 mm/hour Several hours needed for crosslinking to develop; heat speeds the process 6-48 hours recommended Epitope retrieval breaks crosslinks, thereby releasing antigenic sites Excessive retrieval may unmask neoantigens 15 5

6 Immunohistochemistry Negative Reagent Control Tests for nonspecific staining Same patient tissue and processing Use most aggressive retrieval method Separate for each block of patient tissue Primary antibody replaced by: Unrelated antibody Monoclonal antibodies - same isotype Polyclonal antibodies - same animal species Control reagent in staining kit Diluent/buffer fluid 16 Immunohistochemistry Negative Tissue Control Uses tissue known to lack antigen Non-patient tissue One for each antibody per run Same fixation, retrieval and staining Unexpected positive staining? Excessive antibody concentration Excessive antibody retrieval High endogenous biotin Multitissue blocks favored 17 Endogenous Biotin (ANP.22615) Coenzyme in mitochondria; elevated levels in: Hepatocytes, renal tubules, some carcinomas Increased by heat epitope retrieval Needs to be blocked before applying avidin-biotin complex Immediately after epitope retrieval Extensive details in checklist Note 18 6

7 Immunohistochemistry Positive Controls (ANP.22550) Tissue known to contain target antigen Same fixation, epitope retrieval, staining Internal controls OK, but identified in procedure manual Low levels of antigen preferable Favor control tissue on same slide as patient tissue, but batch control OK Maintain records of reactivity 19 Multitissue Block Controls Recommended best laboratory practice Use as combined +/- tissue control Permanent record of sensitivity & specificity of the antibody 1 block can be used for many ab s Useful for: Screening new ab s for sensitivity & specificity Determining optimal titer of antibody 20 Question #5 (answer) Immunohistochemistry: Which of the following may be a cause of non-specific staining in the negative tissue control? A. Excessive antibody concentration B. Excessive epitope retrieval C. High endogenous biotin D. Length of fixation E. Type of fixative used 21 7

8 True or False? Question #6 An immunohistochemical antibody may be used beyond the manufacturer s expiration date as long as the positive and negative controls work properly. 22 Imunohistochemistry Reagents ANP.22432: Are all immunohistochemical reagents used within their indicated expiration dates? Answer very straightforward No explanatory note No exceptions!!! 23 Question #7 Immunohistochemistry: Which of the following is required for Her2 testing? A. Formalin fixation B. Minimum 6 hours fixation time C. Maximum 48 hours fixation time D. Assay validation E. Proficiency testing 24 8

9 Immunohistochemistry Her2 Testing Recent ASCO/CAP agreement Formalin fixation strongly recommended Minimum of 6 hrs. and maximum of 48 hrs. fixation time required ASCO/CAP scoring criteria required Test validation required Proficiency testing required 25 Immunohistochemistry Her2 Test Validation Evaluate sensitivity, specificity, precision Compare to a known validated method Same or alternate method (e.g., FISH) Same or alternate laboratory Minimum 25 cases If other than formalin fixation used, must validate against formalin-fixed tissues 26 Immunohistochemistry Her2 Proficiency Testing Graded proficiency testing Integrated with routine workload No replicate testing No group consensus No interlaboratory communication No referral (except for processing) Evaluation and corrective action 27 9

10 Question #7 (answer) Immunohistochemistry: Which of the following is required for Her2 testing? A. Formalin fixation B. Minimum 6 hours fixation time C. Maximum 48 hours fixation time D. Assay validation E. Proficiency testing 28 Question #8 Which of the following is an appropriate method to document the quality of slide preparations? A. Histotech log B. Pathologist s log C. In patient report 29 Slide Preparations - QC Lab document quality ANP Routine histology ANP Special stain positive controls ANP IHC batch controls Inspector document quality ANP Frozen sections ANP Routine histology ANP Special stains ANP Immunohistochemistry ANP Electron microscopy 30 10

11 Slide Preparations - QC Documentation method is at the discretion of the laboratory Director Must document on each day of use Secondary review QC documents - see GEN Instrument maintenance records - see ANP Maintain records for minimum 2 years 31 Question #9 Which of the following retention periods for Surgical Pathology is INCORRECT? A. Accession log - 2 years B. Wet tissue - 2 wks. after final report C. Paraffin blocks - 5 years D. Glass slides & reports - 10 years E. Maintenance records - for life of the instrument 32 Retention Periods (ANP.12087) Retention periods for Anatomic Path Accession log & QC records - 2 years Wet tissue - 2 wks. after final report Autopsy - 3 months Paraffin blocks - 10 years Glass slides and reports - 10 years Instrument maintenance - life of instrument Policy for preserving integrity and retrieval of materials and records 33 11

12 Question #10 Which of the following Non-Gyn specimens has a high potential for crosscontamination? A. Ascites fluid B. Bronchial washings C. CSF fluid D. FNA of thyroid nodule E. Sputum 34 Non-Gyn Cross-Contamination CYP.07680: Is there a documented policy for ensuring that non-gynecologic specimens with a high potential for cross-contamination are processed and stained separately from other specimens? Applies to any highly cellular specimen Cloudy fluids & FNA s Direct smears 35 Question #11 Which of the following is the correct turnaround time for final autopsy reports? A. All complete within 30 days B. Majority complete in 30 days, remainder within 60 days C. Simple cases within 30 days, complex cases within 60 days D. None of the above 36 12

13 Autopsy Final Reports (ANP & ANP.33150) Most complete in 30 working days All complete in 60 working days Exception: Outside referrals If >60 days, reason for delay must be documented Documentation of ongoing review of TAT records by Director 37 Question #12 Which of the following diagnostic elements is NOT required in the final report of a cancer specimen? A. Tumor grade B. Tumor stage C. Presence/absence of vascular invasion D. Lymph node status E. AJCC TNM Stage 38 Reporting of Cancer Specimens (ANP.21150) must provide data that is sufficient to allow grading and staging of neoplasms Completeness of reports is a patient safety issue Communication of life altering information Use scientifically validated elements CAP Cancer Protocols and Checklists Best practice - Synoptic diagnostic reports QC reports for completeness 39 13

14 Question #13 In a lab using electronic signature, who may verify final reports in addition to the responsible Pathologist? A. Clerk B. Transcriptionist C. Office supervisor D. Histology supervisor E. Another Pathologist 40 Verification of Final Reports (ANP.12100) essential that the laboratory have a procedure that ensures and documents that the responsible pathologist has reviewed and approved the completed report before its release. If signature by another Pathologist: In the occasional situation Report contains both names, as well as the responsibility of each 41 Technical Assistance accred@cap.org , ext

15 Questions? 43 15