Standardization – Where Do We Start?
“If you think of standardization as the best that you know today, but which is to be improved tomorrow, you get somewhere.” – Henry Ford
The first step of Standardization in Histology, not just in a single lab, was taken when it was decided to use one fixative for routine specimens, 10% Neutral Buffered Formalin (NBF). Now we all know that there are other fixatives for special procedures and tissue types and we use them accordingly, but overall, 10% NBF is the standard fixative for routine tissue samples. Who made that decision? Look what standardization of tissue sampling has done for Cytotechnology. The Pap smear and the fine needle aspiration used to be “smeared” on a slide and the quality of the sample and the technologist review time varied greatly from sample to sample. The development of single layer, liquid preparation provided a consistent sample that can now be screened by image analysis, resulting in greatly improved quality, reduced review time and improved patient care. So, why did this process change catch on so fast? The Pathologists were the driving force behind this improvement and demand for improved quality.
Why are the Pathologists and their surrogates, the Pathology Assistant, not championing standardization of Surgical Pathology tissue samples? Is it so unthinkable to use a set of tools that assist in attaining the precise sample? Isn’t it obvious that standardized sample size and thickness will control fixation, reduce processing time, optimize automation and improve the quality of stained tissue samples? Is it worth spending a small increase in time at the grossing bench to realize exponential gains, improvements and cost reduction in the remaining technical tasks in the Histology process? What can we do to convince the Pathologists and the Pathology Assistants that we must partner together to change and standardize tissue sampling?
What do people use for cell blocks? We are using a thermo product that solidifies when you mix the two reagents but I am wondering what others use.
Thanks
Louann
WHAT DO OTHER PEOPLE USE FOR CELL BLOCKS? WE ARE USING A THERMO PRODUCT THAT SOLIDIFIES WHEN YOU MIS THE 2 REAGENTS, BUT WE WERE WONDERING WHAT OTHERS USE. THANKS.
I HAD THE WRONG EMAIL ADDRESS AND THAT IS PROBABLY WHY NO ONE HAS REPLIED BACK.
LOU ANN
HELP. WE HAVE AN ORDER FOR A PNEUMOCYSTIS STAIN AND THE PROCEDURE CALLS FOR FIXING SMEARS OVERNIGHT IN COPLIN JAR WITH GAUZE SOAKED IN 37% FORMALDEHYDE IN THE BOTTOM OF THE JAR. WE DO NOT HAVE 37% FORMALDEHYDE. WHAT DO WE DO?
Since you do not mention the method, I will assume from the fixation method that the stain is a methenamine-Silver stain and since you only have “fresh” smears, I suggest you fix in 95% alcohol (cytospin preparations are fixed this way) and then stain according to your protocol. Another suggestion is to perfrom a Wright-Giemsa or Diff-Quick stain, as they can be perfromed on smears that are methanol fixed. This is a Romanowsky type stain and will give a wide range of color when staining tissues or smears. It is not specific for pneumocystis, but may allow the reviewer to identify sturctures. I hope this helps.
WE ARE HAVING AN ISSUE WITH BREAST TISSUE NOT BEING FIXED. HERE IS WHAT WE DO. FIX OVERNIGHT IN FORMALIN, NEXT DAY 90 MINUTES IN PEN FIX, WASH 15 MINUTES IN RUNNING WATER. THEN PASS FOR THE NEXT DAY. WHEN WE TRY TO CUT THE SECTIONS THEY JUST DO NOT SEEM TO BE FIXED PROPERLY. SO WE PUT THEM BACK ON THE PROCESSOR ON THE REVERSE CYCLE, THEN PASS THEM AGAIN FOR THE NEXT DAY. ANY SUGGESTIONS WOULD BE GREATLY APPRECIATED.
HOW DO I KNOW MY QUESTION TODAY WENT THROUGH?
What is the thickness of the tissue and/or sampleas when fixed overnight? It would be very helpful to know the thickness to determine the penetration and amount of cross-linking. I would also like to know your processing protocol for the tissues processor (include solutions and time in the solution)? Normally, the overnight fixation w/ post fixation in Pen-Fix, a buffered alcoholic formalin solution, should be adequate to complete the fixation and this solution does not require a water wash before placing on the processor and starting the program. If you will provide aditional information, a “fix” to your problem may present itself.
BILL,
DO YOU HAVE A FAX NUMBER THAT I COULD JUST FAX OUR TISSUE PROCESS PROGRAM TO INSTEAD OF EMAILING IT TO YOU. OUR BREAST SPECIMENS ARE SOMETIMES ABOUT 1/2 CM THICK. I KNOW THEY ARE A LITTLE THICK. THANKS
LOU ANN HANDERHAN
Thanks for the information. Without seeing the tissue or the sections cut, I cannot say for certain, but I do not believe you have a fixation problem. The problem seems to be in the procesing and the solutions and times provided do not seem out of the ordinary. I would suggest that if your processor has the options available, add a continuous mix for each solution cycle to help move and exchange the solutions. Consider adding vacuum/pressure at each step to assist infiltration/exchange. I am not a particular fan of increasing the heat. You can also consider to “trim” the samples further to standardize the thicknes to 2mm. Standardization at any step will help reduce variation and leads to reduction in suboptimal performance. Additionally, you can check and make sure that when you process breast tissue, you do not load the basket/rack to capacity to allow for optimum flow of reagents and solutions. Last process suggestion is to set a rigid control on the quality of the reagents on the processor, especially when there are fatty or bloody tissues being processed. Rotate and change out to provide consistant performance of your processing schedules and when using conventional processing and having larger resection specimens processed, I suggest no more the 600-700 cassettes processed before rotating/changing your solutions. Finally, I suggest that you try one thing at a time and validate the process changes. This will require some time and effort, but the benefit will be you will find the issue or combination of issues that are causing the problem and you will be able to prevent the problem as you move forward.
We have the VIP 6 and we love it. This processor has some really amazing features. I cannot enumerate all of them at this time b/c I’d take up lots and lots of space.
The features we use the most that we continue to be very excited about are the solution manager, the bottle check, the automatic solution rotation, cassette count, bulk reservoir tanks, and to help reduce exposure to xylene we definitely use the tubes provided to drain and fill the xylene carboys and we no longer pour solutions in and out of the carboys. The carboys are nice though b/c they are a “wide mouth” size and there is a cap to put on the connector end so if you are walking to and from the processor with a carboy there are no spills from “sloshing” around. If you want me to go into greater detail about any of this please email me back.
The menus are very user friendly. The touch screen is easy to use - we always wear gloves to keep finger prints at bay. The lid is ergonomically designed and easy to open and close.
We have had to request a technician twice - once for a lid sensor and once for a soft ware upgrade / update - but both times they’ve had a tech out here the next day.
I recommended this processor to another lab here in FL and as far as I know they are over the moon about theirs as well.
One other really great thing was that after we purchased our 6 I was sent to CA for a training at Sakura and the information I received there was invaluable. The staff professionalism and knowledge was second to none and I left with a very thorough understanding of the machine. I was able to come back to our lab and provide training to the other staff that use the VIP 6.
No I’m not a sales rep I am just a very happy customer.