Owning Safety in the Autopsy Suite

The hospital security guard placed the deceased patient into the morgue refrigerator while chatting with his co-worker. They walked away without realizing the door did not close completely. Within the hour the automated temperature recording system sent an alert to the lab on the third floor.

The body had been unclaimed, and it stayed on the bottom shelf in the morgue. No one in the hospital wanted to take ownership of it. After a couple of months, fluids began to fill the shelf where the body was. The environmental services staff refused to clean up the mess since some staff were afraid.

The pathologist wanted to finish the autopsy quickly, so he started before the complete patient chart arrived. When the phone rang in the morgue, the physician on the other end of the phone said he believed the patient may have Creutzfeldt-Jakob Disease (CJD).

Managing safety in the autopsy suite can be difficult, but as these case studies show, it is important. One reason for the struggle is that clear ownership of the area is often not defined. Multiple internal departments and even external agencies may work in the morgue and autopsy suite. Pathologists, medical examiners, research physicians, security personnel, nurses, and organ procurement staff are just some of the various people that may perform tasks in the autopsy suite. This can create some unique and unwanted problems. The laboratory should take the lead in making sure all safety regulations are followed and that other users of the suite comply to avoid any unfortunate mishaps.

The morgue should be treated as a laboratory space, and it should be designed similarly to a BSL-3 laboratory space which includes an anteroom. Warning signs indicating the presence of biological and chemical materials should be placed on entry doors. Whenever work is performed in the area, proper personal protective equipment should be utilized. This PPE may include lab coats, gowns, gloves, respirators, and face protection. Make sure PPE is available in the area at all times. The autopsy space should be adequate, such that procedures may be performed effectively and that items such as knives and saws can be stored and used safely. Ventilation should be adequate (with a recommended minimum 12 air exchanges per hour), and the ambient temperature should be monitored as well.

While other personnel may access the morgue body storage refrigerator, it is often the lab or security departments who monitor the temperature. Since CAP inspectors set specific morgue refrigerator temperature ranges (1.1 to 4.4° Celsius), it can be important to communicate with the people who utilize the unit often. If placing or removing a body takes longer than expected, make sure there is adequate communication so that proper documentation of the temperature outages can be made. If a department other than the lab is responsible for temperature monitoring, make sure it is done correctly so there are no citations during an inspection.

Proper decontamination in the morgue is crucial. Instruments, tables, and counters must be disinfected to remove contamination of bloodborne pathogens. Use a chemical germicide for instrument and surface decontamination such as a 10-percent solution of sodium hypochlorite (or bleach). This intermediate-level disinfection will eliminate most bacteria (including Mycobacterium tuberculosis), and all fungi, and it inactivates viruses such as the hepatitis B virus. Rinsing with water or ethanol after disinfecting will help prevent the pitting of any stainless-steel surfaces.

Dealing with Creutzfeldt-Jakob Disease (CJD) in the autopsy suite requires special safety measures. Procedures should be posted in the area directing staff how to handle tissue and clean up in cases where patients are infected with CJD. The intact brain should be fixed in formaldehyde for one to two weeks before handling or cutting in order to reduce the prion activity. Non-disposable implements used with such patients should be immersed in 1N sodium hypochlorite (NaOH) for one hour before reuse. Surfaces on which autopsies occurred should also be immersed in NaOH for one hour for disinfection purposes.

Chemicals are stored and used in the autopsy suite, and standard safe lab practices should be used. Make sure staff is trained in proper the handling, labeling, and storage of chemicals as well as prepared to handle spills. Spill kits should be available and suitable to the chemicals used in the area. If formaldehyde is used, be sure an appropriate neutralizer is available for spill incidents.

As the most involved and best educated about its dangers, laboratory personnel should take the lead in making sure safety is a priority in the morgue, and educate all who may enter the area. Make sure communication is clear about who will use the suite and when- it’s never good to have someone walk in during an autopsy or organ removal. Use signage when necessary, and be willing to help in any unusual situations, because with a morgue, they definitely will arise. Work together as a team with all who utilize the area, and that ownership of safety will translate into safety for all.

 

Scungio 1

Dan Scungio, MT(ASCP), SLS, CQA (ASQ) has over 25 years experience as a certified medical technologist. Today he is the Laboratory Safety Officer for Sentara Healthcare, a system of seven hospitals and over 20 laboratories and draw sites in the Tidewater area of Virginia. He is also known as Dan the Lab Safety Man, a lab safety consultant, educator, and trainer.

Jaffe vs. Enzymatic Method for Serum Creatinine Measurement

The Jaffe and enzymatic methods are the two most common methods for measuring serum creatinine. The Jaffe method is less expensive than the enzymatic assay ($0.30 vs $2.00 per test based on 2014 list prices) but is more susceptible to interferences. Although these tests are not expensive, they are high-volume tests and the savings could be substantial. We were using the enzymatic assay at the University of Utah and estimated that we could save about $50,000 per year by switching to the Jaffe assay; however, we were uncertain whether the Jaffe assay was safe to use due to the potential for interferences. For that reason, we decided to conduct a risk assessment to evaluate the suitability of the Jaffe assay.

Risk is defined as the expected cost of an action. The expected cost has two components: 1) the probability that an event will occur and 2) the consequences or cost of an event:

Risk = prob(event) x cost(event)

The event of interest was misclassification of a patient due to an error in serum creatinine measurement. Nephrologists classify kidney disease based on the estimated glomerular filtration rate which is based on the creatinine value. The distribution of eGFR for patients at our hospital is shown in Figure 1. The dashed lines show decision limits that nephrologists use to classify kidney disease. An eGFR is considered normal or healthy.

We spoke with the nephrologists and learned that they were relatively unconcerned about errors in eGFR in healthy patients (eGFR above 60 ml/min) because there was no potential for harm. Similarly, they felt there was relatively little risk of harm to patients with low eGFRs because these patients are routinely monitored and no major decision would be based solely on a single eGFR measurement. An error in creatinine measurement in a low eGFR patient would be detected by repeat measurements or be inconsistent with other measurements. From the nephrologists’ point of view, the only area of concern was in the region around 60 ml/min.  Patients about 60 ml/min are considered healthy whereas those below 60 ml/min are diagnosed with stage 3a chronic kidney disease. In this zone, an error in serum creatinine could result in a false negative (i.e. observed eGFR greater than 60 ml/min when the true eGFR was less than 60 ml/min). In such cases, a patient may go without care and their disease could progress.  The nephrologists believed that the potential for harm was relatively minor, but potential for harm did exist.

We compared the eGFRs provided by the enzymatic and Jaffee methods to estimate how often patients might be misclassified (Figure 2).1 Focusing on the 60 ml/min decision limit, we found that 17 of 500 (3.4%) of measurements were discordant. Some of these discordant results would be due to imprecision. Discordance due to imprecision would have small differences (bottom of Figure 2) and are unavoidable – they would occur using any method. Discordance due to interference would be expected to have larger differences (top of Figure 2) and could be avoided by using the enzymatic method. We used statistical techniques to estimate the proportion of discordances that were due to interference vs imprecision and found that about 60% of the discordance at the 60 ml/min limit was due to interference. In summary, our risk analysis showed that using the Jaffe method would pose about a 2% rate of avoidable misclassification which presented some potential risk to patients. The nephrologists felt the risk was low but, in theory, disease could unnecessarily progress in a patient with a false negative diagnosis.

Our risk analysis was based on analytical error. We compared magnitude of analytical error to the biological variation in eGFR and found that the analytical error was relatively small in comparison to biological variation (data not shown).  Biological variation was likely to be a more significant cause of misclassification than analytical error.

So, what to do? Was the potential savings of the Jaffe method worth the risk? Some experts recommend against using the Jaffe method. 2-4 On the other hand, most US laboratories use the Jaffe assay. A recent College of American Pathologists proficiency challenge found that 70% of the submitted results were based on the creatinine assay.5

We decided to get the best of both worlds by using BOTH methods. We defined a zone of risk surrounding the 60 ml/min eGFR decision limit (Figure 3). Results in this zone would have some risk of misclassification whereas results outside of the zone would be unlikely to be misclassified using the Jaffee method. All creatinine measurements are initially performed using the Jaffe method. If the result is outside the risk zone, the result is reported. If results fell within the risk zone, they were repeated with the enzymatic method and the results of the enzymatic method are reported. This reflex procedure saves money while avoiding risk. The reflex rate is approximately 15%.

There are circumstances in which one would want to order the best possible test. To that end, we created a special orderable test, based on the enzymatic method, that the nephrologists could use to insure the most accurate results when required. For example, the enzymatic test may be indicated when making decisions regarding biopsies for renal transplant patients. The order volume for the special test has been less than 100 orders per year. 

creat1
Figure 1. Distribution of Estimated Glomerular Filtration rates (eGFR). The distribution is for outpatients at University of Utah for calendar year 2014. The dashed lines indicate decision limits used for classification of chronic kidney disease (15, 30, 45 and 60 ml/min). eGFRs greater than 60 ml/min are considered disease free.
creat2
Figure 2. Discordances in estimated glomerular filtration rate (eGFR) at the 60 ml/min decision limit. The length of each arrow, represents the difference between estimates based on the Jaffe (head) and enzymatic (tail) methods. The dashed line represents two standard deviations of expected imprecision of the difference. Differences greater than 2 standard deviations would most likely be due to analytical interference (loss of specificity).
creat3
Figure 3. Reflex test strategy. The figure shows the distribution of eGFR values for outpatients at the University of Utah.  The dashed lines represent clinical decision limits. The yellow zone represents the range of eGFR values where misclassification could pose a risk to patients. Creatinine is first measured by the Jaffe method. The Jaffe result is reported if the estimated eGFR is outside the yellow zone. If the eGFR is within the yellow zone, the measurement is repeated using the enzymatic method and the result based on the enzymatic method is reported.

References

  1. Schmidt RL, Straseski JA, Raphael KL, Adams AH, Lehman CM. A Risk Assessment of the Jaffe vs Enzymatic Method for Creatinine Measurement in an Outpatient Population. PloS one. 2015;10(11):e0143205.
  2. Cobbaert CM, Baadenhuijsen H, Weykamp CW. Prime time for enzymatic creatinine methods in pediatrics. Clinical Chemistry. 2009;55(3):549-558.
  3. Drion I, Cobbaert C, Groenier KH, et al. Clinical evaluation of analytical variations in serum creatinine measurements: Why laboratories should abandon Jaffe techniques. BMC Nephrology. 2012;13(1).
  4. Panteghini M. Enzymatic assays for creatinine: time for action. Scand J Clin Lab Invest Suppl. 2008;241:84-88.
  5. College of American Pathologists. Chemistry/Therapeutic Monitoring, Participant Survey. 2014.

 

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-Robert Schmidt, MD, PhD, MBA, MS is currently an Associate Professor at the University of Utah where he is Medical Director of the clinical laboratory at the Huntsman Cancer Institute and Director of the Center for Effective Medical Testing at ARUP Laboratories.

Hematopathology Case Study: What’s in Those Histiocytes?

Case history

A 50 year old female with a past medical history significant for Sjogren’s syndrome and ventricular tachycardia s/p ICD placement presented for a routine chest X-ray in which a 1.8 cm spiculated left upper lobe lung mass was identified. A subsequent PET scan revealed FDG avidity. Other Imaging revealed no lymphadenopathy. The patient is a non-smoker and has no other comorbidities. A core needle biopsy with fiducial placement was performed.

Diagnosis

histio1
H&E 10x
histio2
H&E, 20x
histio3
H&E, 50x
histio4
CD3
histio5
CD20
histio6
CD79a
histio7
IgG
histio8
CD68
histio9
CD138
histio10
Kappa ISH
histio11
Lambda ISH

Sections of lung core biopsy material show numerous histiocytes containing eosinophilic intracytoplasmic globular inclusions. An admixed population of plasma cells are seen which are present in aggregates along with mature appearing lymphocytes. The plasma cells also demonstrate globular inclusions within their cytoplasm.

By immunohistochemistry, CD3 highlights scattered mature T-cells while CD20 highlights B-cells present in focal aggregates. Numerous plasma cells are present and are positive for CD138, CD79a, BCL2, and MUM1. By in situ hybridization, plasma cells are greatly kappa predominant. IgG is positive in the majority of the plasma cells with only rare cells staining for IgA and IgM. CD68 is positive in the numerous histiocytes.

IGH gene rearrangement studies by PCR demonstrated was positive, indicating a clonal population.

Overall, the findings are consistent with a crystal-storing histiocytosis with an associated plasma cell neoplasm or low-grade B-cell lymphoproliferative disorder.

Following the diagnosis, the patient received stereotactic body radiation therapy given the localized findings.

Discussion

In this case, the findings are morphologically consistent with crystal-storing histiocytosis (CSH), which is a rare lesion that is the result of intralysosomal accumulation of immunoglobulin. The immunoglobulin is stored as crystalline structures within histiocytes that occupy the vast majority of a mass forming lesion. Multiple sites can be involved, which include bone marrow, lymph nodes, liver, spleen, gastrointestinal tract, and kidney. Most often, the lesion is confined to a single site but occasional generalized forms with multiple organ involvement have been described. CSH is also often associated with B-cell lymphoproliferative disorders or plasma cell dyscrasias, but rarely are the result of chronic inflammatory conditions.

The assessment of CSH requires excellent staining to identify the quality of the histiocytes. As mentioned, CSH will show intracytoplasmic inclusions that are eosinophilic in nature. Mimickers of CSH include mycobacterial and fungal infections, mycobacterial spindle cell pseudotumor, malakoplakia, HLH, storage disorders such as Gaucher’s, as well as histiocytic lesions such as xanthogranuloma, Langerhans cell histiocytiosis, fibrous histiocytoma, Rosai Dorfman disease and rarely other eosinophilic tumors such as rhabdomyoma, granular cell tumor, and oncocytic neoplasms.1

A thorough review of the literature as well as a clinicopathologic study by Kanagal-Shamanna R et al revealed that the localized type of CSH was the dominant presentation in which over 90% of cases showed isolated masses. Per previous reviews, localized lesions were often found in the head and neck as well as lung.2 A study group in which 13 cases that showed CSH, 12 demonstrated an underlying lymphoma or plasmacytic neoplasm. Interestingly, in 5 of the cases, the histiocytic infiltrate was so prominent and dense that it obscured the underlying neoplasm. In these particular cases, immunohistochemistry and PCR were of great importance.

Although the majority of cases of CSH are the result of an underlying lymphoproliferative disorder or plasma cell neoplasm, rare cases of report inflammatory processes have been described, particularly in the setting of an immune mediated process such as rheumatoid arthritis or Crohn disease.

Overall, although a rare entity, it is important to be aware of CSH and its mimickers as this can be an elusive diagnosis to make, especially when the histiocytic infiltrate is dense.

References

  1. Kanagal-Shamanna R, et al. “Crystal-Storing Histiocytosis: A Clinicopathologic Study of 13 Cases,” Histopathology. 2016 March; 68(4): 482-491.
  2. Dogan S, Barnes L, Cruz-Vetrano WP “Crystal-storing histiocytosis: a report of a case, review of the literature (80 cases) and a proposed classification,” Head Neck Pathol. 2012; 6:11-120.

 

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-Phillip Michaels, MD is a board certified anatomic and clinical pathologist who is a current hematopathology fellow at Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. His research interests include molecular profiling of diffuse large B-cell lymphoma as well as pathology resident education, especially in hematopathology and molecular genetic pathology.

Does Price Transparency Improve Lab Utilization?

Physicians often have poor awareness of costs. For that reason, many believe that providing cost information to physicians would increase awareness that, in turn, could improve laboratory utilization. For example, costs of lab tests could be displayed as a field in the computerized provider order entry system. Interventions of this type are attractive because they are relatively inexpensive to implement and do not disrupt workflow with popups. Further, unlike other interventions, cost display is sustainable. Some interventions require constant training and followup whereas cost display is a one-time intervention. For these reasons, organizations are experimenting to see the effect of cost display on laboratory utilization.

Does cost display reduce lab utilization? Studies have shown wide variation in impact. Most studies have focused on orders for laboratory testing and imaging; however, a few studies have looked a pharmaceuticals.  A recent systematic review concluded that cost display is associated with a modest reduction in laboratory utilization.(1) The review included twelve studies on lab utilization and all of these showed improvement.(2-13) However, a more recent study by Sedrak et al. found that cost-display had no impact on utilization.(14) Similarly, two imaging studies found that cost-display had no effect on orders.(4, 15). There was a wide variation in impact: test utilization reduction ranged from 0% to over 30% in some cases. Overall, it appears that cost display tends to reduce utilization; however, it sometimes has no effect as shown in the Sedrak study. So far, cost display has never been associated with an increase in utilization. We have experimented with cost display at University of Utah and, like the Sedrak study, found no effect.

Why is there such a range of effects? Can we predict which organizations are likely to benefit? The short answer is that nobody knows.  The twelve studies on lab utilization where conducted in a wide range of settings (community, academic and pediatric hospitals), included different numbers of tests, or had other differences that could affect results. The way in which costs are displayed also varies. Some sites use the Medicare Maximum Allowable Reimbursement Rate, some use a series of dollar signs to indicate cost categories, and others use charges. It is not clear whether these differences matter.

There are a number of factors that might affect the impact of cost display. For example, cost display might have less impact at an institution that has an effective utilization management program in place because there is less opportunity for improvement. Or, the number of tests with costs displayed may have an impact. For example, some studies have displayed costs for a relatively few number of tests whereas other studies showed costs for a large number of tests.  Cost display for a few tests may send a different signal to providers than providing costs for all tests. Also, we don’t know how long the intervention works. Is there an initial effect that wears off? If so, how long does it last? These questions will need to be resolved by future studies.

In the meantime, should you provide cost feedback at your institution? It is hard to predict what will happen but most evidence suggests that you will see some improvement in utilization. It is not expensive to implement and some organizations have seen a significant impact. At worst, the evidence suggests that you will see no effect on testing behavior.  On balance, cost-display seems like a low-risk intervention.

 

References

  1. Silvestri MT, Bongiovanni TR, Glover JG, Gross CP. Impact of price display on provider ordering: A systematic review. Journal of Hospital Medicine 2016;11:65-76.
  1. Fang DZ, Sran G, Gessner D, et al. Cost and turn-around time display decreases inpatient ordering of reference laboratory tests: A time series. BMJ Quality and Safety 2014;23:994-1000.
  1. Nougon G, Muschart X, Gérard V, et al. Does offering pricing information to resident physicians in the emergency department potentially reduce laboratory and radiology costs? European Journal of Emergency Medicine 2015;22:247-52.
  1. Durand DJ, Feldman LS, Lewin JS, Brotman DJ. Provider cost transparency alone has no impact on inpatient imaging utilization. Journal of the American College of Radiology 2013;10:108-13.
  1. Feldman LS, Shihab HM, Thiemann D, et al. Impact of providing fee data on laboratory test ordering: A controlled clinical trial. JAMA Internal Medicine 2013;173:903-8.
  1. Horn DM, Koplan KE, Senese MD, Orav EJ, Sequist TD. The impact of cost displays on primary care physician laboratory test ordering. J Gen Intern Med 2014;29:708-14.
  1. Ellemdin S, Rheeder P, Soma P. Providing clinicians with information on laboratory test costs leads to reduction in hospital expenditure. South African Medical Journal 2011;101:746-8.
  1. Schilling UM. Cutting costs: The impact of price lists on the cost development at the emergency department. European Journal of Emergency Medicine 2010;17:337-9.
  1. Seguin P, Bleichner J, Grolier J, Guillou Y, Mallédant Y. Effects of price information on test ordering in an intensive care unit. Intensive Care Medicine 2002;28:332-5.
  1. Hampers LC, Cha S, Gutglass DJ, Krug SE, Binns HJ. The effect of price information on test-ordering behavior and patient outcomes in a pediatric emergency department. Pediatrics 1999;103:877-82.
  1. Bates DW, Kuperman GJ, Jha A, et al. Does the computerized display of charges affect inpatient ancillary test utilization? Arch Intern Med 1997;157:2501-8.
  1. Tierney WM, Miller ME, McDonald CJ. The effect on test ordering of informing physicians of the charges for outpatient diagnostic tests. N Engl J Med 1990;322:1499-504.
  1. Everett GD, Deblois CS, Chang PF. Effect of Cost Education, Cost Audits, and Faculty Chart Review on the Use of Laboratory Services. Arch Intern Med 1983;143:942-4.
  1. Sedrak MS, Myers JS, Small DS, et al. Effect of a Price Transparency Intervention in the Electronic Health Record on Clinician Ordering of Inpatient Laboratory Tests: The PRICE Randomized Clinical Trial. JAMA Internal Medicine 2017.
  1. Chien AT, Ganeshan S, Schuster MA, et al. The effect of price information on the ordering of images and procedures. Pediatrics 2017;139.

 

Schmidt-small

-Robert Schmidt, MD, PhD, MBA, MS is a clinical pathologist who specializes in the economic evaluation of medical tests. He is currently an Associate Professor at the University of Utah where he is Medical Director of the clinical laboratory at the Huntsman Cancer Institute and Director of the Center for Effective Medical Testing at ARUP Laboratories.

Pathologist On Call: Fluctuating Parathyroid Hormone with Normal Calcium in an Elderly Man

Case:

A 75 year old Alzheimer’s dementia patient.  Parathyroid hormone (PTH) levels were ordered.

Analyte

(Reference

Range)

05/13 10/13 12/13 7/14 10/14 04/15 09/15 03/16 07/16
PTH

(10-65 pg/mL)

869 42 864 47 1180 48
Ca2+

(8.8-10.2 mg/mL)

10.3 10.5 10 10 9.6 10
Vit D

(2-100 ng/mL)

26 21 39 49 39 57 19

 

Why order PTH? 

PTH is ordered to assess for hyperparathyroidism.  There are two forms of hyperparathyroidism: primary and secondary.  Primary hyperparathyroidism can be caused by a parathyroid (PT) adenoma,  PT hyperplasia, or a non-PT malignancy such as squamous cell cancer or multiple myeloma.  Secondary hyperparathyroidism occurs in response to hypocalcemia which can arise from insufficient intake of vitamin D or chronic renal failure (which results in insufficient vitamin D).   There is weak evidence suggesting a positive correlation between PTH and cognitive decline.(1, 2)  Progression of cognitive decline is slowed when PTH and vit D levels are normalized.

Action of PTH: PTH is a peptide hormone that controls calcium levels in the blood. It is secreted as a prohormone and is cleaved in the blood.  The 34 residue N-terminal fragment is active and has a half-life of about 5 minutes.  The C-terminal end has a half-life or 2 hours and is diagnostically insignificant because it is physiologically inactive.  PTH activates receptors on osteoclasts which causes them to release bone calcium.  PTH also increases renal synthesis of 1,25 OH2 vitamin D which, in turn, increases intestinal absorption of calcium.

What would make the PTH level fluctuate so much?

This is most likely a case of incipient normocalcemic primary hyperparathyroidism (NPH).(3-5)  PTH levels are higher than normal but calcium levels are normal.  PTH levels tend to fluctuate. Calcium can also be sometimes elevated as well.   The disease is thought to be a mild or early form of hyperparathyroidism and 20 percent of patients go on to develop worsening hyperparathyroidism. How should NPH be managed?  Parathyroidectomy or monitoring are the primary alternatives; however, the best way to manage this disease is unknown.

 

References

  1. Lourida I, Thompson-Coon J, Dickens CM, et al. Parathyroid hormone, cognitive function and dementia: A systematic review. PLoS ONE 2015;10.
  1. Björkman MP, Sorva AJ, Tilvis RS. Does elevated parathyroid hormone concentration predict cognitive decline in older people? Aging Clinical and Experimental Research 2010;22:164-9.
  1. Shlapack MA, Rizvi AA. Normocalcemic primary hyperparathyroidism-characteristics and clinical significance of an emerging entity. Am J Med Sci 2012;343:163-6.
  1. Lowe H, McMahon DJ, Rubin MR, Bilezikian JP, Silverberg SJ. Normocalcemic primary hyperparathyroidism: Further characterization of a new clinical phenotype. Journal of Clinical Endocrinology and Metabolism 2007;92:3001-5.
  1. Crowley RK, Gittoes NJ. Elevated PTH with normal serum calcium level: A structured approach. Clinical Endocrinology 2016;84:809-13.

 

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-Robert Schmidt, MD, PhD, MBA, MS is currently an Associate Professor at the University of Utah where he is Medical Director of the clinical laboratory at the Huntsman Cancer Institute and Director of the Center for Effective Medical Testing at ARUP Laboratories.

 

 

Forty Things Every Lab Professional Should know

Hello again everyone! Every few posts on Lablogatory I like to take a small departure from updates about my medical school experience and my Zika public health initiative. This time is more of a shameless plug: I am thrilled and honored to be considered one of ASCP’s Top 40 Under Forty for 2017!

40under40

Looking through the rest of the honorees, I can certainly say I’m in great company. Each person on that list is a prime example of the working values, lessons, and vision that ASCP recognizes in our dynamic field. So, to celebrate my and others’ place on this list, I’ve put together a few thoughts that truly reflect our hard work, talent, and potential as laboratory professionals and what that might mean for each of us. Here are what I consider the “Top 40” lessons that a career in medical laboratory science and laboratory medicine have taught me:

  1. The laboratory is the best melting pot –How many awesome pot-lucks have you had in your breakroom? How many words in new languages have you picked up? All that cultural exposure really contributes to a profound sense of community and humility.
  2. If everything is STAT, nothing is… – need I say more? We know the value of prioritizing and triaging what’s important for patients.
  3. You know a little about a lot of things, and sometimes a lot about a few things – To all my fellow generalists and specialists out there: how good does it feel to directly contribute to a patient’s positive outcome?
  4. Everyone’s got a different TAT – To turn a phrase, we’re all at various stages. Some laboratorians are just starting out and some can “smell” a tricky differential…
  5. Quality control protects everyone – If QC is good, instruments are good. If instruments report good values, results are good.
  6. Accountability is key – Owning up to failures and successes are both important!
  7. Record everything – This is how we protect patients and ourselves as well as improve.
  8. Teamwork is a necessity – It takes a village or, in this case, a full staff…
  9. Serotypes and Stereotypes – We’re not shy! We’re not afraid to jump in and collaborate!
  10. We’re not magicians, but sometimes we are – Impressing other clinicians with our ability to analyze and get results is just part of what we do.
  11. Nurses are our friends – Really, when you’ve got great relationships with the nursing staff you know just how that can make an enormous difference in your work.
  12. Doctors are our friends, too – The best doctors value the laboratory, and its staff!
  13. Ultimately, we’re here for our patients – That’s what it’s all about!
  14. We celebrate each other – How many of your labs have a ‘tech of the year’ award, or service awards? We make sure that we recognize each other’s talents.
  15. We share everything – Life events, stories, experiences, swapping shifts…
  16. Toxic techs are real, but they can be your friend too – All too real in many labs; often they’ve got lots of experience and can be a positive voice for change. Are we listening?
  17. What happens if everyone retires? – Staff turnover can be a challenge, but a combo of great training and communication are key.
  18. What happens if no one retires? Ever? – This occurs too, staff gridlock can be tough to manage and laboratory leadership is part of our role as well.
  19. We ALL have prior experiences – From brand new to near retirement, we’ve all had experience in healthcare; even as patients!
  20. Sometimes, QC just won’t come in range – That’s why relying on protocol and documentation can make all the difference.
  21. Sometimes, things happen even when QC was perfect – Bad days happen! Our drawing board is based on what we do best: analyzing, interpreting, and taking action.
  22. No one can tolerate as much as we can – How many of you have been blamed for hemolysis, or scrutinized for TAT statistics? Let’s call it “character-building experience.”
  23. Trust your training – It’s really your best resource.
  24. Taking initiative is a built-in perk – There will be times when it comes down to one lab tech on a night shift, or one pathologist who’s been paged, to take charge and make decisions.
  25. Watch something, do something, teach something – What better place than a clinical lab to see everything, learn it hands-on, and teach the next person?
  26. Never ending details – All those SOPs really make one appreciate the vast number of details that go into planning anything.
  27. We’re the best part of the hospital for metrics and progress – Diagnostic data comprises 70% of patient information, and 100% of laboratory performance.
  28. Lab week is the best – It feels great to be part of a large family of clinicians in this shared field. It’s also usually around my birthday, so that’s been a personal perk…
  29. Some teachers have years of experience on you – They’ve seen things you may never get the chance to!
  30. Some people will teach you something, even if you’re their supervisor – Everyone brings something to the table, or lab bench, or conference table, or shared microscope.
  31. We choose our words carefully – “These cells are suspicious and require pathology consult with further clinical correlation…” We know our scopes and practices.
  32. We word our choices carefully too – “This specimen was forwarded for pathology review because of our criteria…” We know we’ve got to back up our actions with evidence.
  33. We know office politics, just a little more intense than most people realize – Every hospital has a hierarchy, but laboratorians know we’re all on the same team.
  34. We’ve got an SOP for that – Literally, we have one for everything.
  35. We can come up with solutions with very limited information – Requisitions don’t always carry the highest level of clinically relevant guidance. (Test: Hgb A1c, Note: repeat from 1 hour ago).
  36. Sometimes we cannot find a solution, despite endless information – There are times when laboratory data is not enough to definitively make diagnoses, that’s just part of medicine.
  37. We all have the potential to be laboratory leaders – We’ll all have moments to take initiative and demonstrate our talents at one point or another.
  38. We are all real clinical scientists – The change to calling it “medical laboratory scientists” is one of the best changes ever. In my opinion, we are true clinical and critical scientists.
  39. It’s our job to promote our role and our field!
  40. Never stop learning!

I think the last two points need no explanation. Thank you for taking the time to read my “Top 40” Laboratory Lessons. If you have a great lesson you’ve learned, add it to the comments below! Don’t forget to check in next month for another update on my work and don’t forget to vote for ASCP’s Top Five! All the Top 40 Under Forty nominees are eligible to be in the Top Five based on your votes and comments!

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Constantine E. Kanakis MSc, MLS (ASCP)CM graduated from Loyola University Chicago with a BS in Molecular Biology and Bioethics and then Rush University with an MS in Medical Laboratory Science. He is currently a medical student at the American University of the Caribbean and actively involved with local public health.

 

Molecular Perspectives of Diffuse Large B-cell Lymphoma

Case

A 100 year old female was seen for follow-up for her hypertension, mild renal impairment, and fatigue. The patient also stated a three week duration of pain in the area of the right upper quadrant that radiates to her back. No other symptoms or concerns were expressed.

An abdominal CT was performed which showed a 6.6 x 2.1 cm soft tissue mass in the right posterior chest wall that also encases the 11th rib. Given the concern for a malignant process, a core needle biopsy was obtained for histology only.

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H&E, 20x
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H&E, 50x
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CD20
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CD10
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BCL6
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MUM1
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Ki-67

The H&E stained sections show a diffuse infiltration of atypical lymphoid cells that are large in size with irregular nuclear contours, vesicular chromatin, and some with prominent nucleoli. Frequent apoptotic bodies and mitotic figures were seen. By immunohistochemistry, CD20 highlights the infiltrating cells, which are positive for BCL2, BCL6, and MUM1 (major subset). CD10 is negative within the atypical lymphoid population. CD3 highlights background T-cells. Ki-67 proliferation index is approximately 70%. EBER ISH is negative.

Overall, the findings are consistent with diffuse large B-cell lymphoma, NOS with a non-GCB phenotype by the Hans algorithm.

Discussion

Diffuse large B-cell lymphoma (DLBCL) is the most common B-cell lymphoma in adults comprising 30%-40% of new adult lymphomas. Approximately 50% of patients will be cured, even in advanced cases; however, those that fail conventional therapy ultimately succumb to their illness.1 Up to 30% of patients have refractoriness or relapse after initial therapy with rituximab based regimens, particulary R-CHOP (ritixumab, cyclophosphamide, doxorubicin, vincristine, and prednisone).

In the era of new molecular techniques and in the context of the heterogeneous nature of DLBCL, it has become important to accurately assess cell of origin (COO) as this has prognostic implications. With the seminal paper from Alizadeh and colleagues, gene expression profiling (GEP) by a microarray platform produced the concept of germinal center (GCB) versus activated B-cell (ABC) types of DLBCL.2 In the context of prognosis and R-CHOP therapy, the GCB type has a 3 year PFS of 75% as opposed to the ABC type that has a 3 year PFS of 40% (P<.001).3 Although GEP analysis is considered the ideal modality for determining COO, however, given the constraints of most modern hematopathology practices, surrogate immunohistochemical algorithms were developed to aid in COO determination. Of the multiple algorithms, the Hans algorithm is the most widely used and accepted for IHC determination of COO.

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Adapted from Hans et al., Blood, 2004

The COO determination has revealed multiple genetic alterations that are shared between the GCB and ABC phenotype while distinct changes have been identified in each type. Molecular mechanisms at play include, but are not limited to, histone modification, blocks to terminal differentiation, cell cycle activation, PI3K/AKT signaling activation, mTOR pathway activation, as well as a multitude of other signaling cascades. A common shared dysregulated pathway between GCB and ABC types include mutations in CREBBP and EP300, which is in approximately 30% of DLBCL cases and slightly enriched in the GCB group. Mutations/deletions in these genes result in inactivation and alter histone modification subsequently thought to contribute to acetylation of BCL6, which is a key regulatory protein in lymphomagenesis. Up to 33% of DLBCL have mutations in MLL2, which has a broad effect on chromatin regulation and epigenomic alteration. Approximately 35% of DLBCL cases with up to two- to three-fold increase in ABC type cases have genetic alterations in BCL6, particularly chromosomal rearrangements and mutations in the 5’ sequence. Pasqualucci et al also described other factors that lead to BCL6 inactivation, including mutations in MEF2B and FBXO11.4

ABC type DLBCL often displays canonical pathway activation of NF-ƙB signaling, which ultimately promotes survival, proliferation, and inhibition of apoptosis. This potentially is a result of alterations in the CBM signalosome (CARD11, BCL10, and MALT1) with up to 10% of ABC-DLBCL cases having a mutation in CARD11. Another modality of ABC activation is through the B-cell receptor signaling pathway in which 20% of cases harbor a CD79A or CD79B mutation.  Interestingly enough, recurring mutations in MYD88 occur in ~30% of ABC-DLBCLs, which results in upregulation of NF-kB and Janus kinase-signal transducers. Other important genetic alterations include involvement by signaling pathways of spleen tyrosine kinase (SYK), PI3K, Bruton tyrosine kinase (BTK), and protein kinase C-β (PKC-β).

GCB type DLBCL often expresses CD10, LMO2, and BCL6 and has a less understood and distinct pathway when compared to ABC-DLBCL. The most common alterations include t(14;18) IGH-BCL2 (30-40%), C-REL amplification (30%), EZH2 (20%) and PTEN mutations (10%). These changes are almost never seen in ABC-DLBCL.

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Adapted from Pasqualucci et al., Semin Hematol, April 2015

Although the findings in GCB and ABC type DLBCL are described, they are not absolute and multiple studies done by whole exome sequencing (WES) and whole genome sequencing (WGS) have elucidate further complexities and genetic changes. In 2015, data from Novak and colleagues revealed CNAs and mutations that were associated EFS, which also underscored the important 24 month milestone for survival.5 Morin et al in 2013 described 41 novel genes in DLBCL which demonstrated just how complex and heterogeneous DLBCL truly is (see figure below).6

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Adapted from Morin et al., Blood, 2013.

As common as DLBCL is, there is much to be understood not only for lymphomagenesis, but for correct classification and risk stratification. Many targeted therapies have been designed and are in trials at the moment, but given the nature of DLBCL and its heterogeneity, more work on the molecular front is needed. Modalities for assessing COO are currently on the market but are not widely used. Perhaps COO determination by IHC may be an antiquated method, but it is currently the standard by which most pathologists practice. Overall, DLBCL in all its forms is not a uniform entity that can easily be defeated, but requires thought and diligence in achieving a cure.

 

  1. Lohr, JG et al. “Discovery and prioritization of somatic mutations in diffuse large B-cell lymphoma (DLBCL) by whole-exome sequencing,” Proc Natl Acad Sci USA. 2012; 109(10): 3879-3884
  2. Alizadeh AA, et al. “Distinct types of diffuse large B-cell lymphoma identified by gene expression profiling,” Nature 2000, 403:503-11
  3. Sehn, L and Gascoyne, R “Diffuse large B-cell lymphoma: optimizing outcome in the context of clinical and biologic heterogeneity,” Blood. 2015;125(1):22-32
  4. Pasqualucci, L and Dalla-Favera, Riccardo, “The Genetic Landscape of Diffuse Large B Cell Lymphoma,” Semin Hematol. 2015 April; 52(2): 67-76
  5. Novak, AJ et al. “Whole-exome analysis reveals novel somatic genomic alterations associated with outcome in immunochemotherapy-treated diffuse large B-cell lymphoma,” Blood Cancer Journal (2015) 5
  6. Morin, R et al. “Mutational and structural analysis of diffuse large B-cell lymphoma using whole-genome sequencing,” 2013;122(7):1256-1265

 

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-Phillip Michaels, MD is a board certified anatomic and clinical pathologist who is a current hematopathology fellow at Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. His research interests include molecular profiling of diffuse large B-cell lymphoma as well as pathology resident education, especially in hematopathology and molecular genetic pathology.