Opinions Importance of Standardization for Predictive Prognosis David J. Dabbs, MD Chief of Pathology, Magee-Womens Hospital University of Pittsburgh School of Medicine Estrogen and progesterone receptors have both prognostic and predictive value, but the predictive value significantly outweighs the prognostic value. Hormone receptor levels are utilized to determine whether a patient is a candidate for serum estrogen receptor modulation therapy (SERM). Standardization of procedure and reporting is crucial for hormone receptors, as it is for HER2/neu and other diagnostic tests that crucially affect patient therapies. A highly visible example is the test for the ProTime, specifically the international ratio (INR) that determines the plasma ProTime using a standardized control as comparison. When a patient sits in the phlebotomy chair in order to have blood drawn for this test, the phlebotomist knows exactly which tube color to choose to collect the blood tissue specimen. In an identical fashion, anatomical pathologists need to pay greater attention to detail for the collection of fresh tissues from the operating room. Hormone receptors, like many other predictive prognostic tests, deteriorate rapidly beginning in the operating room when the tissue is devitalized from its blood supply. It is of utmost importance to collect these samples fresh as soon as possible, section them at 5 mm intervals and submerse them in a large volume of formalin in order to begin the fixation process. Exposure to formalin is not equal to fixation time. Fixation time actually is substantially longer than the time of exposure of a specimen to formalin. Fixation continues once exposure to formalin has ceased, as there are continuous chemical reactions and chemical cross-links that alter tissue proteins as a result of being exposed to formalin. An ample number of studies indicate that the ideal minimum exposure time to 10% neutral buffered formalin is 8 hours. Simultaneously, it is crucial for pathologists to realize that the entire outcome studies that had been performed over the decade were performed on the basis of tissues fixed in 10% neutral buffered formalin. Given the more recent data on formalin exposure times, it is critical for the laboratory to record the approximate time of exposure that tissues have to formalin. This is a quality issue, especially nowadays when more sophisticated prognostic and predictive tests that affect patients outcome are performed. Clearly, the hematoxylin and eosin stain is a very robust stain that will pretty much look the same whether the tissue is exposed to 10% neutral buffered formalin for one hour or 1000 hours. However, this is not the case for other prognostic and predictive factors, especially estrogen and progesterone receptors. At a minimum, it is prudent to utilize immunohistochemical hormone assays that have been approved by the FDA. These assays have been rigorously examined and have been shown to be substantially equivalent to other tests, including the previously utilized dextrancoded charcoal assays. Pathologists do have the prerogative to utilize analyte-specific reagent hormone receptor tests, but the burden is on the laboratory in order to demonstrate equivalence to the FDA approved assays . In the real world, it is virtually impossible to adequately and rigorously make this equivalent testing. In addition, should laboratory test results differ between an ASR performed test and an FDA approved test, there could potentially be legal implications. The crucial aspect of documenting exposure time to formalin is now realized and has been included on the College of American Pathologists Anatomical Pathology checklist for accreditation inspections. At Magee-Womens Hospital, breast specimens retrieved from the biopsy site are promptly transported to the pathology laboratory where the receipt time Connection 2008 | 54 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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