... the biggest hurdle in India is suboptimal fixation and processing of tissues. Though I agree that IHC has the limitations mentioned in the above article, I do believe these can be surpassed. Just as it is important to do IHC it is equally important to validate IHC. Every signing pathologist should have sound knowledge of pitfalls in IHC technique and also of histology to avoid errors. Most of the times the issue is a positive or a negative test result and quantification only arises in some markers. I have seen pathologists changing diagnosis based on a falsely negative or positive IHC and this is where quality control and basic confidence in histology helps. While variability in reagents and methods used make it impossible to have universally standardized IHC, regular in-house quality control measures ensure reproducibility of a given test. Every laboratory should ensure run-to-run reproducibility with use of controls. Use of the standard quality reagents (not cutting costs too much) and defined protocols for preparation of slides and antigen retrieval will help. Participation in external quality assurance programs also helps. Connection: In your opinion, what is the biggest hurdle for standardization? As a part of a cancer referral institute, I think the biggest hurdle in India is suboptimal fixation (usually less fixation) and processing of tissues. Because of suboptimal fixation, some tissues are irreversibly damaged. Most tissues are fixed in either dilute formalin/ formal-saline or nonbuffered formalin; or a big specimen is stuffed in a small container resulting in a non-uniform fixation and autolysis. At the Tata Hospital (where I work) sheer large quantity of work also complicates the issue of quality control. Connection: United Kingdom National External Quality Assessment Service (UK NEQAS) helps to ensure that clinical laboratory test results are accurate, reliable and comparable wherever they are produced. Similarly, Nordic Immunohistochemical Quality Control (NordiQC) - an independent, scientific, non-profit organization is dedicated in the quality assessment of IHC in Northern Europe. What is the equivalent of UK NEQAS and NordiQC in India? None exists. We are attempting to set the ball rolling by offering a national QC program, and I hope it gets going. Connection: Internal quality procedures are essential for the reproducibility of the IHC performance in the individual laboratory. In contrast, external quality assessment (EQA) systems retrospectively and objectively compare staining results from many laboratories by means of an external agency. An EQA system allows the identification of insufficient stains and inappropriate protocols as well as identification of possible interpretation problems. What is the name of your EQA system and how many laboratories in India follow it? As of now we are participating for inter-laboratory comparison (EQAs) of IHC as part of the National Accreditation Board for Testing and Calibration Laboratories accreditation with one laboratory in Mumbai only (http://www.nabl-india.org/). The Program does not have a formal name. I am aware that a laboratory in the city of Mumbai ­ namely P.D. Hinduja National Hospital (http://www.hindujahospital.com/focus.html) - is CAP-accredited and participate in IHC EQAs. Connection: What are the main functions of your external quality assessment (EQA) scheme? Is EQA involved in collaborations with other countries (US, UK, Canada, etc.?) As of now, we send test cases for antibodies accredited to a laboratory in the EQA program - We finished one cycle of comparison with S. L. Raheja Hospital and Well Spring Labs. As of now, no international EQAs exist. Connection: How would you like to standardize IHC in India? 1. Each IHC laboratory should have a daily standardization with low positive controls. 2. All laboratories in the country should be trained to understand disasters of poor processing and fixation. 3. There should be a central testing laboratory which quality checks random samples of IHC from the laboratories in question. Connection: How well is the pre-fixation process standardized? Is it at all possible to standardize this process? Pre-fixation process as noted above is highly variable, there is a need to educate all laboratories and surgeons in the country sending tissues to pathology laboratories as to the appropriate means of transport of tissues. Whenever we participate in CMEs (continuous medical education) this is a point we strive to get across and I believe that this problem could be tackled. Connection: The Members of the Ad-Hoc Committee on Immunohistochemistry Standardization (Appl Immunohistochem Mol Morphol 2007;15:124­133) strongly discourage non-formalin fixatives and encourage formaldehyde as the fixative of choice. What fixatives are used in your laboratory, and at what concentration? Do you recommend the use of any other fixatives and why? We suggest use of 10% neutral-buffered formalin as the most costeffective fixative for all tissues. Fixatives like B5 or alcoholic formalin helps preserve hormone receptors better (cf. Shet T, Raut U, Kadam J, Chinoy R. Effect of routine fixation on the immunohistochemical demonstration of hormone receptors in breast cancer. Mammology 2007;3:39-42), but cost is a major limiting factor in a country like ours. In a study in our institute, we observed that Bouins fixation harms IHC demonstration of ER/ PR, and neutral-buffered formalin emerged as the best all-round fixative. Connection 2008 | 20 April 2008, VOL 11 Connection IHC STANDARDIZATION AROUND THE WORLD In this issue Q&A with Patho Contents APRIL 2008, VOL 11 2 3 4 Editorial George L. Kumar, PhD Featured Laboratory The Osamura Editorial Immunohistochemistry (IHC) Standardization Around the World George L. Kumar, PhD Managing Featured Laboratory The Osamura Laboratory Laboratory headed by Prof. Robert Yoshiyuki Osamura, MD, Q&A Ask the Experts: On Immunohistochemistry (IHC) Standardization Professor Leong is Medical Di time interval between removal of tissue and immersion in fixative, the temperature of tissue storage Connection: How would you like to standardize IHC in Australia? As discussed above, standardization Connection: Antigen retrieval is essential in immunohistochemistry (IHC) in order to restore epitope Connection: Is a universal image analysis system feasible? No, not until we standardize the all impo Q&A Fernando Soares, MD, PhD University of São Paulo, São Paulo, Brazil Dr. Fernando Soares is F Connection: In your opinion, what is the biggest hurdle for standardization? Probably education in l There are no standards in Latin America. We always follow the manufacturers protocol during our firs Q&A Bryan R. Hewlett, ART, MLT Consultant Technologist to the Anatomic Pathology EQA program of There is no standardization of AR steps circumstances, it would be impossible toand, undera the pre Connection: How would you rate European (UK NEQAS, NordiQC) and US IHC standards to Canadian IHC sta Q&A Prof. Chen Jie Prof. Cui Quancai Peking Union Mediacl College Hospital, Beijing, China Prof. Connection: According to Goldstein et al. Appl Immunohistochem Mol Morphol 2007;15:124­133 Immunohis Connection: Is it true that a particular histology feature may be better demonstrated by other fixat Connection: What constitutes standardization of image analysis as applied to immunohistochemistry (I Q&A Dr. Tanuja Manjanath Shet Dr. Vani Parmar Tata Memorial Hospital, Mumbai, India Tanuja Manj ... the biggest hurdle in India is suboptimal fixation and processing of tissues. Though I agree th Connection: Is it true that a particular histology feature may be better demonstrated by other fixat Connection: Can you comment on the internal and external quality control (EQC) procedures followed i Q&A Prof. Robert Yoshiyuki Osamura Department of Pathology, Tokai University School of Medicine Connection: In your opinion, what is the biggest hurdle for standardization? The biggest hurdle for the standardization of image ... appropriate for pre-screeninganalysis is of the staining quality. Connection: Why is standardization of image analysis in diagnostic pathology important? Because the Q&A James F. Happel, DLM (ASCP), HTL Technical Director of Surgical Pathology, Research and Deve Connection: United Kingdom National External Quality Assessment Service (UK NEQAS) helps to ensure t Connection: The American Society of Clinical Oncology (ASCO) and the College of American Pathologist would recommend that standardization Ibegin with identifying a reliable and trustworthy source ... Interview Immunohistochemistry for Oestrogen and Progesterone Receptors Dr. Andrew Lee Consultant H Connection: What is the difference between the H score and the Allred score? Which is better? What d Connection: Can you comment on the burden in the laboratory, if one changes from a current ER/PR ass Opinion & Interview IHC Standardization: A Dako Perspective Dr. Ole Rasmussen R&D Director, Connection: Dako has developed Readyto-Use Antibodies for in vitro diagnostic applications. How is t Articles UK NEQAS-ICC & ISH: Historical perspective, current role, future directions Andy Dodso UK NEQAS-ICC in the 1990s In his first year as Scheme Organiser, Keith oversaw the transition to sub The application could be argued to represent a field change in terms of the rigour with which the an Assessment teams consist of four assessors, who view slides around a multi-headed microscope and sco The archive which UK NEQAS holds, both in terms of stained slides and methodological data, must sure For Immunocytochemistry and FISH RESULT: RUN 80L SLIDE: NEQAS Laboratory No: XXX Mr. A. Scientist De Figure 6. Feedback on results has always been given high priority, and for many years this has been a b c d Figure 7. The antigen chosen by Gerry Reynolds for his very first assessment run was kap Bibliography Selected UK NEQAS-ICC & ISH papers. Ibrahim M, Dodson AR, Barnett S, Fish D, Jasani Articles Nordic Immunohistochemical Quality Control (NordiQC) An Organization for External Quality A parameters (i.e. results interpretation and reporting) (4, 5). In an EQA setting, by circulating ser CD79a (Fig. 2) Among 112 laboratories submitting stains in the latest run, most used mAb clone JCB11 References 1. Rhodes A, Jasani B, Barnes DM, Bobrow LG, Miller KD. Reliability of immuno-histochemic Fig. 2. CD79a A. Optimal CD79a staining of the tonsil using the monoclonal antibody (mAb) clone JCB Standardization of Ki-67 Immunohistochemical Staining for Diagnosing Grade of Gastrointestinal Strom was conducted in 49 GIST cases. The concordance rate for the evaluation results at three laboratorie CB pH6 a b c d TE pH9 e f g h Autoclave 121° C/10 min Water bath 95° C/40 min Microwave 50 Table 1. Correlation between NCC and STD methods R2=0.9483 Categories of proportion NCC Method 3 Opinions Importance of Standardization for Predictive Prognosis David J. Dabbs, MD Chief of Pathol is documented and serves as a surrogate marker for the initial exposure to formalin. Since the first Opinions The New Era for ER and PRIts time to Standardize! Dr. Ian Ellis, B.Med.Sci. BM, MS, FRCpa et al 2001). The main reason for false-negative results is due to inefficient heat-induced epitope ( Standardization of HER2 TestingInconsistency Raises Questions Opinions Sunil S. Badve, MD, FRCPath rence seen in these trials is in the order of 50%. This is the major reason for all the excitement a which now requires expression of HER2 by at least 30% of tumor cells (instead of 10%). It has also r IHC CONSENSUS MEETING, JANUARY 27 2008, SANTA BARBARA, CA, USA , IHC CONSENSUS MEETING, JANUARY 27, Richard Cartun, PhD, Sunil Badve, MD Jon Askaa, PhD Søren Nielsen, HT, CT, Mogens Vyberg, MD Elizab Dako Abstracts Abstracts presented at the 30th Annual San Antonio Breast Cancer Symposium December Dako Abstracts Amplification of ESR1 may predict resistance to adjuvant tamoxifen in postmenopausal Dako Abstracts Abstracts presented at the United States and Canadian Academy of Pathology (USCAP) A Dako Abstracts Metastatic Pancreatic Endocrine Tumors in the Liver Express KOC Briones AJ, Bourne P Dako Abstracts Merkel Cell Carcinomas Express K Homology Domain Containing Protein Overexpressed in Dako Abstracts Immunohistochemical Analysis of KOC/IMP3 in Malignant Pleural Mesothelioma Xu H, Sim Dako Abstracts KOC, TTF-1 and CDX2 Discriminate Small-Cell Carcinoma from Carcinoid and Pancreatic Dako Publications Publications Co-authored by Dako: In Press Li L, Xu H, Spaulding B, Cheng L, Si Dako Meetings 2007 - National Society for Histotechnology Meeting. 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