DIVISION OF HEMATOPATHOLOGY - UPMC - Department of Pathology

DIVISION OF HEMATOPATHOLOGY

HEMATOPATHOLOGY HANDBOOK

FOR RESIDENTS AND FELLOWS

August 2016

STEVEN H. SWERDLOW, MD

DIRECTOR, DIVISION OF HEMATOPATHOLOGY

GRANT BULLOCK, MD LYDIA CONTIS, MD

MIROSLAV DJOKIC, MD SARAH GIBSON, MD

NIDHI AGGARWAL, MD SARA MONAGHAN, MD

The Division acknowledges the help of Ms. J. Klimkowicz in putting this

handbook together and keeping it up to date.

TABLE OF CONTENTS (Ctrl +click on blue hyperlink to go to section)

IMPORTANT TELEPHONE NUMBERS LIST 5 GENERAL OUTLINE FOR HEMATOPATHOLOGY ROTATION 7 HEMATOPATHOLOGY PROGRESSIVE GOALS AND OBJECTIVES 11 RESIDENT EVALUATION METHODS AND DOCUMENTATION 18 CONFERENCE SCHEDULE AND RESPONSIBILITIES 40 PEDIATRIC AND GENERAL HEMATOLOGY LABORATORY EXPERIENCE 26 GENERAL/SPECIAL HEMATOLOGY LABORATORY EXPERIENCE CHECKLIST 29 PEDIATRIC HEMATOPATHOLOGY CHECKLIST 41 UPMC PRESBYTERIAN SHADYSIDE AUTOMATED TESTING LABORATORY 49 PATHOLOGIST REVIEW FORM/CHP ATL PATHOLOGIST REVIEW FORM CLINICAL EXPERIENCE IN HEMATOLOGY 51 CLINICAL HEMATOLOGY/PERFORMANCE OF BONE MARROW EXPERIENCE 52 PERFORMANCE OF BONE MARROW ASPIRATIONS & BIOPSIES 53 HEMATOPATHOLOGY ROTATION PERFORMANCE OF MARROW BIOPSIES AND ASPIRATES FORM 55 FLOW CYTOMETRY LABORATORY EXPERIENCE 89 FLOW CYTOMETRY ROTATION CHECKLIST 91 FLOW CYTOMETRY PANELS, AVAILABLE ANTIBODIES, GUIDELINES, 60 TEST SPECIFICATIONS FOR CLINICAL FLOW CYTOMETRY LABORATORY 71 ICD9 CODES FOR FLOW 73 ADULT BONE MARROW EXPERIENCE 106 GENERAL TRAINEE RESPONSIBILITIES DURING BONE MARROW ROTATION 108 SPECIFIC GUIDELINES FOR RESIDENTS AND FELLOWS ON BONE MARROW SERVICE 110 BONE MARROW ADEQUACY CRITERIA 111 POLICY FOR REVIEW OF BONE MARROW ASPIRATES AND BIOPSIES 112 BONE MARROW CHECKLIST 113 FORMS AND TEMPLATES FOR BONE MARROW SERVICE 123 RECOMMENDATIONS FOR CONSISTENT TERMINOLOGY 135 AJCC PROTOCOL FOR EXAMINATIOM OF SPECIMINS FROM PATIENTS WITH

HEMATOPOIETIC NEOPLASMS INVOLVING THE BONE MARROW 138 BONE MARROW LABORATORY TEST SPECIFICATIONS 150 SUMMARY OF TEST SPECIFICATION FOR ANCILLARY LABORATORIES 151 BONE_MARROW_AFTER_HOURS_PROCEDURES 154

TABLE OF CONTENTS (cont.) LYMPH NODE EXPERIENCE 158 SURGICAL PATHOLOGY MANUAL: LYMPH NODE PROTOCOL 160 SURGICAL PATHOLOGY MANUAL: SPLEEN PROTOCOL 170 LYMPH NODE GROSS DICTATION-TEMPLATE 171 POLICY FOR SOLID TISSUE SPECIMENS 172 INSTRUCTIONS FOR FRESH TISSUE BIOPSIES RECEIVED FROM OUTSIDE INSTITUTIONS 173 FRESH CASE LYMPH NODES AND OTHER SOLID TISSUES SENT FOR FLOW CYTOMETRY 174 HELPFUL HINTS FOR HANDLING CONSULT BLOCKS & SENDING OUTSIDE BLOCKS TO HISTOLOGY 175 RULES FOR HISTOLOGY 176 GENERAL FORMATTING REQUIREMENTS 179 LYMPH NODE/SOLID TISSUE ORGANIZATION OF SIGNOUT MATERIAL 185 HEMATOPATHOLOGY CASE WORKSHEET 187 LYMPH NODE ROTATION CHECKLIST 192 AJCC PROTOCOL FOR EXAMINTION OF SPECIMENS FROM PATIENT WITH NON-HODGKIN LYMPHOMA/LYMPHOID NEOPLASMS 201 AJCC PROTOCOL FOR THE EXAMINATION OF SPECIMENS FROM PATIENTS WITH HODGKIN LYMPHOMA 217

IMMUNOHISTOCHEMISTRY 222

IMMUNOSTAINS/IN-SITU HYBRIDIZATION LABORATORY AND ORDERING INFORMATION 223 STAINS FREQUENTLY USED IN HEMATOPATHOLOGY: CODES AND REACTIVITIES 225 COMPLETE IMMUNOHISTOCHEMICAL STAIN ABBREVIATIONS/CODES 228 IN-SITU HYBRIDIZATION PROBES AVAILABLE 236 IHC/ISH REPORTING TEMPLATES 237

MOLECULAR DIAGNOSTIC AND CYTOGENETICS 240 FLUORESCENCE IN SITU HYBRIDIZATION – PITTSBURGH CYTOGENETICS LABORATORY 242

COPATH AND DICTATION POINTERS 250 DICTATING & PROOFING TISSUE REPORTS 253 SYNOPTICS 256

WEB-BASED RESOURCES 273

Contents of Supplementary Information

See the following hard copy supplementary information: 1. Schedules

Master Hematopathology Flow Cytometry Conference Journal Club Patient Safety and Risk Management Hematopathology Conference Pediatric Tumor Board Conference Schedule Hematopathology Core Resident Rotation

2. Forms to turn into Hematopathology Coordinator Jessica Klimkowicz: Performance of Marrow Biopsies and Aspirates Form (2) Laboratory Hematology Check List Flow Cytometry Experience Checklist Lymph Node Experience Checklist Pediatric Hematology Experience Checklist Bone Marrow Experience Checklist

3. Material for Laboratory Hematology

Red Cell Morphology Classification Complete Blood Count Evaluation Continuing Education in Clinical Chemistry and Hematology Conference Responsibilities

4. Miscellaneous Progressive Goals and Objectives Faculty/Fellow Phone List Sure-handed Sampling/Easing the Trauma of Bone Marrow Collection Resident Evaluation Methods Dictating and Proofing Tissue Reports CD Hematopathology Handbook for Residents and Fellows Automated Hematology Instrumentation Grossing Fresh Lymph Nodes (PowerPoint Presentation) Neutrophil Oxidative Burst Assay (NOBA) Hemoglobinopathies (PowerPoint Presentation) Chromatin interpretation guide for hemoglobinopathies (PDF)

HEMATOPATHOLOGY FACULTY

Long Range Pager

In House Pager

Office # Coordinator/Secretary

Grant Bullock, MD, PhD 412-958-6254 10356 412-624-7523 412-647-5191

Lydia Contis, MD 412-433-9364 2296 412-647-0264 412-647-5191

Miroslav Djokic, MD 412-958-5267 14609 412-692-2128 412-647-5191

Sarah Gibson, MD 412-958-5723 13155 412-647-4162 412-647-5191

Nidhi Aggarwal, MD 412-958-6063 4467 412-864-6185 412-647-5191

Steven H. Swerdlow, MD 412-392-7445 2826 412-647-5191 Jessica Klimkowicz 412-578-9423

FELLOWS Long Range Pager

In House Pager

Office # Coordinator/Secretary

Casey Gooden, MD 412-958-2236 4678 412-647-1877 N/A

Rebeca Leeman-Neill, MD 412-270-0352 8507 412-647-0435 N/A

Erika Moore, MD 412-958-2246 4684 412-578-9239 N/A

Lymph Node Assistant

Lisa Fitchwell 412-958-7432 10768 412-647-5869 N/A

Michelle Asturi --------------- --------------- 412-647-0263 N/A

Cytogenetics/Hours of 412-641-6688 (Weekend pager: 412-917-9458-messages will be checked until 3PM)

FISH Lab 412-641-3434

Dr. Urvashi Surti 412-917-9333 --------------- 412-641-4267

Dr. Susanne Gollin --------------- --------------- 412-624-5390 Noel Eisel Harrie

Maureen Sherer --------------- --------------- 412-641-6685 ---------------

Technologist Pager 412-917-9458 (Sat./Sun./Holidays until 3:00pm)

Molecular Diagnostics 412-864-6150 (CLB)

Molec Fellows 412-864-6155

Molec Sign-Out 412-864-6153

Dr. Zoltan Oltvai --------------- --------------- 412-864-6150

Dr. Tim Oury --------------- --------------- 412-648-9659

Dr. Marie DeFrances --------------- --------------- 412-648-8346

Miscellaneous Phone Number Location Supervisor Lead Technologist

Bone Marrow Lab 412-647-0263 G325.1 Celina Fortunato Celina Fortunato 412-802-3272

Bone Marrow Audix 412-802-3273 “Non-Stat” Requests

Bone Marrow Sign Out 412-647-5881 G315 --------------- ------------------

Histology 412-647-7660 CLB Marina Rahman 412-864-6123

Tisha Harrison 5am-1:30pm immunoperoxidase issues

Mike Swiatkowski 7-3:30 Routine histology and special stain issues

Mary Mullen 3-11:30 Evening routine & immunoperoxidase issues

IPEX 412-647-7663

Lymph Node Sign Out / Resource Room

412-647-5262 G323 --------------- ------------------

Consult Accessioning 412-864-6175 CLB 9032 Celina Fortunato Celina Fortunato 412-802-3272

Automated Testing Lab 412-647-1022/ heme bench 76199

5th

Fl CLB Katie Mulvey 412-647-6517

Mary Vernetti/Chris Morain 641-4662/624-2462 (Heme)

SHY Automated Testing Lab

412-623-1595 WG02.18 Darla Lower 623-1595

Flow Laboratory 412-864-6173 CLB 9032

Pager 412-565-9553

Ruth Bates 412-864-6180 Flow Laboratory Extras 412-864-6182

SHY Hematology Lab 412-623-6011 Shadyside Fl G-Main

Darla Lower 412-623-1595

Tammy Garrett

Microlab Adult 412-647-3727 PUH A802 Frances Hardic 412-647-7711

CHP ATL 412-692-5325 412-692-5665

CHP Lawrenceville

Lorraine Heffelfinger 412-692-7611 / Marianne Riazzi 412-692-9836

GENERAL OUTLINE FOR HEMATOPATHOLOGY

ROTATION

General Outline for Hematopathology Rotations

Core Rotation for Residents The approximately three-month core hematopathology rotation offers the resident an introduction to the many facets of this complex field. It is hoped that the resident will begin to become familiar with the multiparameter approach to adult and pediatric diagnostic hematopathology (bone marrows and lymph nodes) as well as with techniques used in general and special hematology laboratories, and the flow cytometry laboratory. Finally he/she will learn about major neoplastic and non-neoplastic disease entities that involve the hematopoietic and lymphoid cell lineage. If interested, more advanced subsequent rotations can be arranged in one or more areas within the division. It is fully recognized that the resident cannot fully achieve all of the objectives listed within a period of three months. The different sections within the rotation are usually, but not always carried out in the order they are listed here. The educational resources noted below are located in rooms G304 (conference room), G315 (bone marrow sign-out room) and G323 (lymph node sign-out room) depending on their subject matter. Cytogenetics is a separate rotation, but residents will learn how cytogenetic data is used in diagnostic hematopathology.

Syllabus Statement Concerning Students with Disabilities If you have a disability for which you are or may be requesting an accommodation, you are encouraged to contact Dr. Swerdlow, Dr. Gibson or their designate prior to your rotation so reasonable accommodations can be made.

Elective Rotations This handbook also serves as a resource for upper level resident rotations that can concentrate on any of the areas in hematopathology.

Fellow Rotations This handbook also is a major supplement to the fellow handbook as they also follow the basic procedures outlined here for the rotations that overlap with hematopathology resident rotations. The expectations are greater for the fellows in terms of their knowledge base, clinical skills and ability to utilize multiple resources to make specific diagnoses. Accordingly they are given enhanced responsibilities. Hematopathology Twelve Week Core Resident Rotation

Week Activities

1 Orientation with Dr. Gibson or designee. Lymph Node

2 Lymph Node

3 Lymph Node

4 Lymph Node

5 Peds/Wet & ASCP image set/BM tech review

6 Peds/Wet

7 Peds/Wet

8 Days 1-3 AM Shadyside (Go to Hemepath Conference Wed AM) Days 3 PM – 4,5 Flow Rotation

9 Adult Bone Marrow

10 Adult Bone Marrow



1. Lymph Node Pathology (~ 4 weeks) 1. Lymph Node Sign Out. 2. Review of educational materials (See Lymph Node Experience section).

Goals and Objectives: 1. Learn the use of multiparameter approach to diagnostic lymph node pathology as

well as extranodal hematopoietic/lymphoid proliferations.

2. Learn normal nodal histology and basic reactive patterns.

3. Begin to develop a basic understanding of Hodgkin’s Lymphoma, the non-

Hodgkin’s lymphomas and reactive lymphoid hyperplasias. Be able to diagnose

straightforward cases of the above.

4. Complete lymph node rotation checklist.

2. Pediatric Hematopathology and General/Special Hematology Laboratory Experience (~ 3 weeks) Trainees should report to the pathologist signing out CHP bone marrows and to Dr. Contis or her designate after their general rotation orientation or at the start of the rotation. Trainees should also meet with Dr. Contis or her designate at the midpoint to review progress on the rotation and at the completion of the rotation. Inform the pathologist covering the general hematology laboratory as well. The trainee will give one ~15 minute presentation near the end of this section of the rotation. This period should also be used to review the ASCP image series on normal and abnormal peripheral blood and bone marrow examinations.

Pediatric Hematopathology Experience 1. Introduction to basic bone marrow/peripheral blood interpretation.

2. Pediatric Bone Marrow Sign out.

3. Observation of pediatric marrow examination procedures.

4. Review pediatric material from Automated Testing Laboratory and Flow

Cytometry Laboratory.

5. Review of educational materials (See Pediatric Hematopathology Experience

section).

Goals and Objectives: 1. Develop basic skills in the interpretation of peripheral blood, bone marrow and

fluid evaluations.

2. Develop familiarity with issues unique to pediatric hematopathology, both

pathologic and clinical.

3. Develop basic skills in hematopathologic ancillary studies.

4. Complete pediatric hematopathology checklist.

5. Complete pediatric bone marrow observation form.

General/Special Hematology Laboratory Experience

1. Automated Testing Laboratory Experience.

2. Special Hematology Testing Experience.

3. Review of educational materials.

4. Presentation to technologists.

Goals and Objectives: 1. Learn the major aspects of non-neoplastic hematology including red blood cell,

white blood and platelet abnormalities and the way in which the laboratory helps

in the diagnosis and follow-up of hematologic/lymphoid neoplasms.

2. Understand the principles of urinalysis and how it is used to help diagnose renal

and systemic disorders.

3. Understand automated hematology and urinalysis instrumentation.

4. Develop understanding of how a large complex patient-oriented clinical

laboratory facility is managed. This includes an appreciation of the scope of the

testing, testing methodology and documentation of test accuracy.

5. Learn the scope and practices of “Special Hematology” testing and how it is

utilized to diagnose hematologic disorders.

6. Complete general/special hematology experience checklist.

3. Clinical experience in Hematology/Performance of Bone Marrows (with Hematology/Oncology Division) (2 ½ days)

Attend varied clinics at UPMC-Shadyside/Hillman Cancer Center to observe the clinical aspects of hematology and understand the needs of both patients and their physicians. Trainees are expected to learn how to perform bone marrow aspirations and biopsies. They should aim to observe and then perform several marrows. Because it is expected that during this rotation residents will perform no more that 5 marrows, they should complete this requirement on their later VA rotation (Dr. M. Melhem). Be sure to complete the BM performance form that requires signatures of the person who supervised your marrow examinations and the pathologist who reviewed the slides. NOTE: Appropriate dress is required to see patients (white coat, men need to wear a tie).

Goals and Objectives: 1. Gain experience performing bone marrow aspirates and biopsies.

2. Learn more about clinical implications of hematopathology diagnoses and impact

on patients as a person.

3. Provide opportunities to perform bone marrow examinations.

4. Learn what type of consultations clinicians expect from hematopathologists.

5. Complete the bone marrow performance form.

4. Flow Cytometry Laboratory Experience (2½ days)

Understanding of flow cytometric immunophenotypic techniques and interpretation of the resultant data is an integral part of all the bone marrow and lymph node rotations. In addition, however there is a brief concentrated exposure to the flow cytometry laboratory including the technical aspects of flow cytometry and the basic operation of a flow cytometry laboratory. The resident should report to Ruth Bates or their designate.

Goals and Objectives: 1. Understand sample preparation; basic flow cytometry, quality control, gating on

specific cell populations, and determination of positive versus negative staining

and methods of data presentation.

2. Know indications for testing, taking into account cost effective medicine

3. Complete flow cytometry checklist.

5. Adult Bone Marrow Experience (~ 4 weeks) A. Limited Sessions with Adult Bone Marrow Technologist.

B. Responsibility for review of selected cases prior to sign-out.

C. Participation in sign-out with staff.

D. Review of educational materials (See Adult Bone Marrow Experience section).

Goals and Objectives: 1. Learn normal and abnormal blood cell morphology.

2. Learn basic approach to bone marrow aspirate, biopsy and particle preparation

interpretation.

3. Begin to become familiar with the use of ancillary studies used in the diagnosis of

bone marrow examinations.

4. Begin to develop a basic understanding of the more common neoplastic and non-

neoplastic disorders which involve the marrow: acute and chronic leukemias,

myelodysplasias, myeloproliferative disorders, anemias, thrombocytopenias,

leukopenias, thrombocytosis, leukocytosis, infections (including HIV), and

metastatic neoplasms. Be able to diagnose straightforward cases of the above.

5. Complete bone marrow rotation checklist.

Hematopathology Progressive Goals and Objectives

Competency Core Rotation - 1st to 3rd Year Resident Beginning of Rotation

Core Rotation – 1st to 3rd year Resident Later in Rotation

Elective Rotation - 3rd and 4th year Resident

Fellow First Year

Fellow Second Year Post Fellowship Experience

Professionalism

Reliable, punctual, appropriate appearance, ethical behavior, sensitive to issues of diversity, HIPAA compliant

Same as near beginning of rotation but projects more confidence and handles difficult situations with greater ease.

In addition to elements already noted, can help advise more junior trainees and serve as a more senior role model.

In addition to elements noted for residents, functions so that others perceive fellow more like a junior faculty member. Create a professional CV. Conduct a successful job search if not continuing as a fellow.

In addition to prior accomplishments, interacts with other faculty and clinicians like a more confident junior faculty member, able to construct and maintain professional c.v. and biosketch

Patient Care

Preview marrow aspirate smears with direct faculty guidance. Review cases, record observations, formulate differential diagnosis.

Preview marrow aspirate smears semi-independently, directly interact with technologists. Review cases, record observations, formulate more complete differential diagnosis

Write and dictate reports for most routine cases.

Independently work-up and complete the majority of cases.

Able to provide a complete diagnostic report to attending faculty with minimal required changes.

Formulate list of immunohistochemical stains, cytochemical stains, flow antibody combinations to resolve differential diagnosis. Review data from ancillary studies

Formulate more educated list of immunohistochemical stains, cytochemical stains, flow antibody combinations to resolve differential diagnosis. Review

Independently order ancillary studies in a resource conscious way on most routine cases.

Independently order ancillary studies in a resource conscious way on routine and most complex cases.

Independently order ancillary studies in a resource conscious way on virtually all cases.




Fellow First Year


and record interpretation.

data from ancillary studies and record more complete interpretation.

Gross specimens for lymphoma work-up with directed supervision.

Gross specimens for lymphoma work-up with supervision as needed (after consulting fellow or appropriate faculty).

Gross specimens for lymphoma work-up with limited supervision and select ancillary testing independently for most routine cases.

Gross specimens for lymphoma work-up with very limited supervision and select ancillary testing independently for the majority of cases. Be able to help instruct junior trainees.

Able to gross and triage specimens independently and to supervise and instruct more junior trainees.

With explicit directions, interact with clinicians and support staff.

With less explicit directions, interact with clinicians and support staff.

Function as a critical consultant to clinical physicians and support staff with some supervision.

Independently function as a critical consultant to clinical physicians.

Able to supervise more junior trainee’s presentations and provide guidance for preparation.

Be able to provide basic review of peripheral blood and interpret most common hematology tests.

Be able to provide basic review of peripheral blood, fluids and urines and interpret most standard hematology tests.

Provide consultative/laboratory report for general and special hematology tests, peripheral blood and fluid reviews working with faculty on more complex cases and with limited assistance on less complex cases.

Provide consultative/laboratory report for general and special hematology tests, peripheral blood and fluid reviews on simple and complex cases relatively independently but with final approval by faculty member.

Provide consultative/laboratory report for general and special hematology tests, peripheral blood and fluid reviews in all cases with only limited supervision.




Fellow First Year


Observe how others handle laboratory management issues.

Participate with faculty/senior technical staff in laboratory management issues.

Get directly involved in laboratory management issues with supervision.

Get involved in laboratory management issues with more limited supervision.

Participate in continuing education of technologists and support staff to improve patient care.

Present at inter-departmental CPC conferences with extensive supervision.

Present at inter-departmental CPC conferences with less direct supervision.

Present at inter-departmental CPC conferences with limited supervision.

Independently present at inter-departmental CPC conferences.

Presents cases at clinical CPC conferences without supervision.

Medical Knowledge

Knowledge of morphology and immunophenotype of normal lymph node, spleen, bone marrow and peripheral blood. Knowledge of multiparameter approach to diagnosis of hematologic disorders.

Know criteria for major neoplastic and non-neoplastic hematopathologic entities. Know specific approach used to diagnose major neoplastic and non-neoplastic hematologic entities.

Know criteria for some of the less common hematopathologic entities in addition to those for major entities.

Have an extensive knowledge of broad range of neoplastic and non-neoplastic hematopoietic/lymphoid disorders and other disorders that involve or affect the hematolymphoid system including the pathologic and clinical aspects of these disorders.

Further increase hematopathology knowledge base in terms of rare entities and variations within more common entities. Learn more about the type of cases that lack a definitive diagnosis. Demonstrates ability to apply and discuss knowledge learned from instructional workshops or conferences attended.

Recognize some of the more common neoplastic and non-neoplastic disorders. Know basic immunophenotypic/ genotypic/cytogenetic features where

Recognize additional common neoplastic and non-neoplastic disorders and know ways in which specific entities are further subdivided. In addition to basic

Recognize most common and some uncommon neoplastic and non-neoplastic disorders of the hematolymphoid system and know the immunophenotypic, cytogenetic and genotypic characteristics.

Recognizes broad range of hematologic disorders and recognizes when a definitive diagnosis cannot be rendered or where consultative help may be required.

Demonstrates an appreciation of the limitation(s) of current diagnostic schemes/classification systems (i.e. shows recognition for “gray zones” in diagnosis).




Fellow First Year


appropriate. ancillary data features, know pathophysiologic features of major entities. Complete greater than 80% of resident version of rotation checklist.

Completes more of appropriate checklists and sees more entities previously encountered through reading. Complete greater than 90% of resident version of rotation checklist.

Complete “extended version” of all rotation checklists.

Know basic components of complete blood count and how they are obtained.

Know basic components of complete blood count and other major hematology tests and how they are obtained including major pitfalls. Also know basic principles of fluid and urinalysis interpretations. Know disease entities where diagnosis is based in large part on hematology laboratory testing.

Know full armamentarium of hematology testing, the purpose of each test and how to interpret combinations of tests. Know new developments in hematology instrumentation.

In addition to resident accomplishments, know details of more esoteric testing and what is on the horizon for laboratory hematology. Know how to evaluate new instrumentation.

Be able to teach others about laboratory hematology including factual and interpretive elements.

Practice-based Learning

Become familiar with basic hematopathology educational resources.

Search literature for information pertaining to cases and apply it to diagnostic appraisals at sign-out

Critically analyze literature and other sources of new information pertaining to cases.

Have a broad knowledge of the hematopathology resources and literature and be able to apply this

Master all skill expectations listed for more junior residents and first year fellow. Use information




Fellow First Year


and at conferences. information to daily practice including dealing with unusual cases

independently to alter personal practice.

Start to develop diagnostic differentials for some of the more common neoplastic and non-neoplastic disorders with significant faculty input. Construct reports based on others’ examples.

Knows the differential diagnoses to consider for more commonly encountered neoplastic and non-neoplastic disorders. Improve reports based on comments received back from the faculty.

Able to construct more extensive differentials and apply knowledge by deciding what stains and ancillary testing would aid in distinguishing amongst the diagnostic possibilities being considered. Produce reports based on comments received back from the faculty who require few, if any, changes.

Demonstrates ability to use textbooks and medical literature to construct a differential diagnosis for most cases and decide what ancillary testing would be useful. Develop complete reports that reflect divisional style based on continued input from faculty, integrating the best suggestions from varied individuals. Independently use other colleagues and faculty as learning resources.

Demonstrates ability to apply knowledge from medical literature in constructing a diagnostic differential or choosing an appropriate work-up strategy of stains, ancillary testing, etc. Have established style for producing final reports that reflects an integration of input from varied faculty and integrate additional suggestions received on reports. Demonstrates ability to utilize other professional colleagues as learning resource(s).

Interpersonal/Communication Skills

Present with clarity in conference settings with significant faculty

Present with clarity in conference settings with minimal faculty




Fellow First Year


guidance.

assistance.

Works well with technologists and support staff and learns from them.

Greater interaction with technologists, including demonstrating an ability to teach them.

Can serve as a greater resource for technical staff.

Demonstrates the ability to present information to technologists and junior residents at levels appropriate for the audience.

Able to educate technologists and residents with ease in more impromptu settings as appropriate. Proactively seeks opportunities to educate others.

Contact clinicians to obtain clinical and other information.

Able to convey straightforward information to clinicians.

Discuss preliminary reports and diagnoses with clinicians with ease. Able to convey more complex information to clinicians and consulting pathologists.

Able to convey complex information to clinicians and consulting pathologists and can answer questions about diagnoses or work-up. Also able to discuss clinical implications of diagnoses in depth.

Able to function as a junior faculty in terms of providing consultative information to staff pathologists at UPMC and elsewhere as well as with clinicians.

System based Practice

Know and utilize basic aspects of resources available in health system i.e. computer systems (CoPath, MARS), laboratories (hematology, molecular diagnostics, cytogenetics, histology), grossing, bone marrow laboratories.

Know and more fully utilize resources available in health system.

Learn about outside regulatory agencies/organizations. Develop an appreciation of basic healthcare/pathology related financial issues. Perform a mock CAP inspection, if possible.

Learn about the administrative and technical functions of running the Division of Hematopathology. Perform a mock CAP inspection, if possible.

Demonstrates understanding of more complex personnel management issues. Understands the various components of a diagnostic hematopathology service and the interaction with other related, but separate services, such as




Fellow First Year


cytogenetics and molecular laboratories). Has basic understanding of hospital budgetary issues that may be specific to hematopathology or pathology in general.

RESIDENT EVALUATION METHODS AND DOCUMENTATION in the Division of Hematopathology

A) Hematopathology Test for Residents:

1. Subject Material:

Images, glass slides and/or laboratory data from areas of rotation that have been completed: o Bone marrow o Laboratory hematology o Lymph node

2. Evaluation Method:

Review information provided

Examine glass slides and/or images with other laboratory/clinical data provided

Select best diagnosis from list of choices 3. Dates administered – Approximately 1½ weeks prior to completion of core hematopathology rotation

blocks.

B) Completion of Checklists according to rotation service (Bone Marrow, Lymph Node, Pediatric Hematopathology, Laboratory Hematology)

C) Department of Pathology Resident Evaluation Forms (covering multiple competencies)

D) Documentation of Observation and Performance of Bone Marrow Aspirates and Biopsies by Completion of Bone Marrow Performance Form

E) Documentation of Conference Attendance at Journal Club, Interesting Case Conference, Wednesday

morning Hematopathology Conference

F) Faculty and staff observation of performance in conferences and sign-out and general observations regarding interpersonal relationships, communication skills and professionalism, including utilization of departmental and extra-departmental resources

G) Personal Meeting with Director or designate at end of core rotation segments

The Pathology Milestone Project

A Joint Initiative of

The Accreditation Council for Graduate Medical Education

and

The American Board of Pathology

September 2013

Please see the website (https://www.acgme.org/acgmeweb/Portals/0/PDFs/Milestones/PathologyMilestones.pdf) for most current version of Pathology Milestones

https://www.acgme.org/acgmeweb/Portals/0/PDFs/Milestones/PathologyMilestones.pdf

i

The Pathology Milestone Project

The Milestones are designed only for use in evaluation of resident physicians in the context of their

participation in ACGME-accredited residency or fellowship programs. The Milestones provide a framework

for the assessment of the development of the resident physician in key dimensions of the elements of

physician competency in a specialty or subspecialty. They neither represent the entirety of the dimensions

of the six domains of physician competency, nor are they designed to be relevant in any other context.

ii

Pathology Milestone Group

Chair: Wesley Y. Naritoku, MD, PhD

Vice Chair: C. Bruce Alexander, MD

Betsy D. Bennett, MD, PhD

Mark Brissette, MD Margaret

M. Grimes, MD, MEd Robert D.

Hoffman, MD, PhD Jennifer

Leigh Hunt, MD

Julia C. Iezzoni, MD

Rebecca Johnson, MD

Resident Member: Jessica Kozel, MD

Resident Member: Ricardo M. Mendoza, MD

Steven P. Nestler, PhD

Miriam D. Post, MD

Suzanne Z. Powell, MD

Gary W. Procop, MD, MS

Stephen Black-Schaffer, MD

Jacob J. Steinberg, MD

Linda Thorsen, MA

3

Milestone Reporting

This document presents milestones designed for programs to use in semi-annual review of resident performance and reporting to ACGME. Milestones are knowledge, skills, attitudes, and other attributes for each of the ACGME competencies organized in a developmental framework from less to more advanced. They are descriptors and targets for resident performance as a resident moves from entry into residency through graduation. In the initial years of implementation, the Review Committee will examine milestone performance data for each program’s residents as one element in the Next Accreditation System (NAS) to determine whether residents overall are progressing.

For each reporting period, review and reporting will involve selecting the level of milestones that best describes each resident’s current performance level in relation to milestones. Milestones are arranged into numbered levels. Selection of a level implies that the resident substantially demonstrates the milestones in that level, as well as those in lower levels. (See Reporting Form diagram on page v below.) A general interpretation of each level for pathology is below:

Level 1: The resident is a graduating medical student/experiencing first day of residency.

Level 2: The resident is advancing and demonstrating additional milestones.

Level 3: The resident continues to advance and demonstrate additional milestones; the resident consistently demonstrates the majority of milestones targeted for residency.

Level 4: The resident has advanced so that he or she now substantially demonstrates the milestones targeted for residency. This level is designed as the graduation target.

Level 5: The resident has advanced beyond performance targets set for residency and is demonstrating “aspirational” goals which might describe the performance of someone who has been in practice for several years. It is expected that only a few exceptional residents will reach this level.

4

Additional Notes

Level 4 is designed as the graduation target but does not represent a graduation requirement. Making decisions about readiness for graduation is the purview of the residency program director. (See the following NAS FAQ for educational milestones on the ACGME’s NAS microsite for further discussion of this issue: “Can a resident graduate if he or she does not reach every milestone?”) Study of milestone performance data will be required before the ACGME and its partners will be able to determine whether Level 4 milestones and milestones in lower levels are in the appropriate level within the developmental framework, and whether milestone data are of sufficient quality to be used for high stakes decisions.

Some milestone descriptions include statements about performing independently. These activities must follow the ACGME supervision guidelines. For example, a resident who performs a procedure or takes independent call must, at a minimum, be supervised through oversight.

Answers to Frequently Asked Questions about the NAS and milestones are available on the ACGME’s NAS microsite:

http://www.acgme-nas.org/assets/pdf/NASFAQs.pdf.

http://www.acgme-nas.org/assets/pdf/NASFAQs.pdf

5

ACGME Report Form

The diagram below presents an example set of milestones for one sub-competency in the same format as the milestone report worksheet. For each reporting period, a resident’s performance on the milestones for each sub-competency will be indicated by:

selecting the level of milestones that best describes the resident’s performance in relation to the milestones or selecting the “Has not Achieved Level 1” option

Selecting a response box in the middle of a level implies that milestones in that level and in lower levels have been substantially demonstrated.

Selecting a response box on the line in between columns indicates that milestones in lower levels have been substantially demonstrated as well as some milestones in the higher columns(s).

Copyright (c) 2013 The Accreditation Council for Graduate Medical Education and The American Board of Pathology. All rights reserved. The copyright owners grant third parties the right to use the Pathology Milestones on a non-exclusive basis for educational purposes. 1

PATHOLOGY MILESTONES ACGME Reporting Worksheet

PC1: Consultation: Analyzes, appraises, formulates, generates, and effectively reports consultation (AP and CP)

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

Understands the implications of and the need for a consultation

Observes and assists in the consultation

Understands the concept of a critical value and the read-back procedure

Understands and applies Electronic Medical Record (EMR) to obtain added clinical information

Understands that advanced precision diagnostics and personalized medicine (e.g., molecular diagnostic testing) may be applied to patient care for genetic, neoplastic and infectious disorders, and population health

Prepares a draft consultative report (verbal or written)

Performs timely, clinically useful consultation for requests for products or additional testing

Understands rationale for the critical value list

Knows the critical value list and participates in the critical value call-back of results

Understands the importance of accurate, timely, and complete reporting of laboratory test results

Understands the role of specific advanced precision diagnostics and personalized medicine assays, and how results affect patient diagnosis and prognosis, and overall

Prepares a full consultative report with a written opinion for common diseases

Prioritizes and presents patient care issues for report after call

Answers routine pathology questions, drawing upon appropriate resources

Applies the escalation procedure for failed critical value call-backs

Effectively communicates preliminary results on cases in progress

Understands pre-analytic issues and quality control for advanced precision diagnostics and personalized medicine

Independently prepares a full consultative written report with comprehensive review of medical records on common and uncommon diseases

Runs report conference after call

Develops a portfolio of clinical consultation experience

Recommends new or alternate escalation procedures for failed critical value call-backs as needed

Suggests evidence-based management, prognosis, and therapeutic recommendations based on the consultation

Provides consultation, as needed, to clinicians about utilization and interpretation of advanced

Proficient in pathology consultations with comprehensive review of medical records

Demonstrates an expanded portfolio of clinical and patient care experience with pathology consultation

Participates in intuitional processes of generating the critical value list

Is proficient in consultation regarding test utilization and treatment decisions based on advanced precision diagnostics and personalized medicine


patient care precision diagnostics and personalized medicine

Comments:

Suggested Evaluation Methods: Direct observation, Retrospective peer review, Portfolio, Feedback from clinical colleagues (360 evaluations), Peer review, HIPAA training

documentation provided


PC2: Interpretation and reporting: Analyzes data, appraises, formulates, and generates effective and timely reports (CP)

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

Identifies key elements in the health care record

Observes and assists in the interpretation and reporting of the diagnostic test

Understands indications for common tests

Uses clinical correlation to interpret and report test results

Describes the test platform and methodology

Accurately interprets and reports the results

Understands and applies algorithms in the work-up for common diagnoses

Limits and focuses a differential diagnosis

Knows the current and up- to-date literature about the test result

Prepares a differential diagnosis for abnormal results

Understands and applies algorithms in the work-up for common and uncommon diagnoses

Able to lead discussion on developing a differential diagnosis based upon clinical information

Interfaces with clinical team to recommend tests, based upon current literature

Knows potential confounding factors that may contribute to erroneous results

Understands and prudently applies justification for approval of costly testing

Proficient in using health care records and clinical information to develop a limited and focused differential diagnosis

Critically evaluates and applies the current literature

Proficient in the interpretation and reporting of clinical pathology test results in the context of the patient’s medical condition

Proficient in algorithms in the work-up for all diagnoses

Writes policies on algorithms for testing

Comments:

Suggested Evaluation Methods: Direct observation, Simulation, Feedback from clinical colleagues (360 evaluations), Retrospective peer review, Quality management

results


PC3: Interpretation and diagnosis: Demonstrates knowledge and practices interpretation and analysis to formulate diagnoses (AP)

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

Recognizes the importance of a complete pathology report for patient care

Begins to make connections between clinical differential diagnosis, gross, and microscopic pathologic findings

Generates a list of next steps (ancillary testing; has awareness of options available) needed to refine differential in the clinical context

Distinguishes normal from abnormal histology and recognizes confounding factors

Correlates the clinical differential diagnosis with gross and microscopic pathologic findings

Recognizes appropriate ancillary tests and refines knowledge of “next steps” and proper utilization for application to differential

Consistently recognizes and correctly identifies common histopathologic findings (develops a "good eye"); able to troubleshoot (e.g., tissue artifacts, processing and sampling issues)

Analyzes complex cases, integrates literature, and prepares a full consultative written report with comprehensive review of medical records

Interprets ancillary testing results in clinical context

Makes accurate diagnoses reliably, appreciates the nuances of diseases, and is able to independently troubleshoot confounding factors

Assesses, analyzes, and is able to distinguish subtle differences in difficult cases

Proficient in interpretation with comprehensive review of medical records

Seeks appropriate consultations

Comments:

Suggested Evaluation Methods: Direct observation, Simulation, Feedback from clinical colleagues (360 evaluations), Examination


PC4: Reporting: Analyzes data, appraises, formulates, and generates effective and timely reports (AP)

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

Applies prior knowledge and draws on resources to learn normal gross anatomy, histology, and special techniques

Recognizes the role of the surgical pathologist in the management of patients, including the utilization of cancer staging

Attends and contributes to gross and microscopic conferences

Brings clinical/ancillary information to sign-out (e.g., radiology, prior cases, reading about case)

Generates preliminary report and/or Preliminary Autopsy Diagnosis (PAD) (for autopsy) prior to sign- out with attending staff/responsible physician

Is aware of accepted standards for turn- around time

Becomes familiar with synoptic reporting

Reliably applies knowledge of gross and histologic features in formulating a diagnosis for common entities; able to present at gross conference

Selects, orders, and interprets clinical/ancillary information to refine a differential diagnosis

Composes a complete and accurate report on common specimens

Able to generate a cause of death and manner of death for autopsy

Completes routine preliminary and final reports within standards for turn- around time

Knows when synoptic reporting/template required

Reliably applies knowledge of gross and histologic features in formulating a diagnosis for common and uncommon entities

Seeks appropriate consultations

Integrates clinical/ancillary information into report

Composes a complete and accurate report on common and uncommon specimens, including autopsies

Completes complicated preliminary and final reports within standards for turn-around time

Communicates effectively with family members, when applicable

Able to complete synoptic report accurately

Participates in intradepartmental peer review consultation with colleagues

Manages ambiguity and uncertainty in result interpretation and ancillary testing

Produces timely reports with complete accurate gross and histopathologic findings, including ancillary studies; integrates evidence-based medicine/current literature and knowledge

Ensures communication of results to appropriate audiences

Keeps current with evolving standards of synoptic reporting

Comments:

Suggested Evaluation Methods: Direct observation, Narrative, Feedback from clinical colleagues (360 evaluations), Retrospective peer review


PC5: Procedure: Surgical Pathology grossing: Demonstrates attitudes, knowledge, and practices that enables proficient performance of gross examination (analysis and appraisal of findings, synthesis and assembly, and reporting) (AP)

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

Understands common surgical procedures and the resultant specimens

Recognizes the importance of grossing for the interpretation of histology and management of patients

Applies prior knowledge and draws on resources to learn normal gross anatomy

Demonstrates familiarity with the gross manual or a similar reference book

Ensures and maintains the integrity of specimens to avoid cross-contamination or identity mix-up

Correctly describes and appropriately samples common surgical specimens, including necessary tissues for ancillary studies in correct media/fixative

Correlates clinical and/or radiological information

Understands the components of an appropriate and complete report

Develops time management skills

Applies principles of grossing to newly encountered specimen types

Correctly describes and appropriately samples common and uncommon surgical specimens

Recognizes when additional gross sampling is necessary for diagnosis or staging

Produces reports that contain all the necessary information for patient management; edits transcribed reports effectively

Demonstrates increasing efficiency in grossing specimens

Has a portfolio of grossed specimens that demonstrates competency across a range of complex specimens

Correctly describes and appropriately samples all specimen types

Dictates complete, logical, and succinct descriptions

Efficient in grossing surgical specimens

Demonstrates an expanded portfolio of competency in grossing specimens of a widely diverse and complex specimen type

Proficient in the performance of surgical pathology gross examination

Proficient in the production of complete, logical, and succinct descriptions

Comments:

Suggested Evaluation Methods: Direct observation, 360 evaluation, Periodic self-assessment, Narrative, Portfolio, Quality management


PC6: Procedure: Intra-operative consultation/ frozen sections: Demonstrates attitudes, knowledge, and practices that enables proficient performance of gross examination, frozen section (analysis and appraisal of findings, synthesis and assembly, and reporting) (AP)

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

Understands common surgical procedures and the resultant specimens and potential intraoperative consultation/frozen section/intra-operative cytology (IOC/FS)

Is aware of indications and contraindications for IOC/FS and follows protocols and regulations

Procures tissue for diagnosis under supervision

Prepares IOC/FS that are of good interpretive quality

Understands and follows correct call-back guidelines

Aware of limitations of techniques and interpretation

Discusses with pathology attending staff member(s) any requests that are contraindicated

Correctly selects tissue for frozen section diagnosis independently

Able to perform high quality IOC/FS on technically difficult and multiple specimens; performs IOC/FS within turn- around time standards

Effectively communicates the diagnosis and is cognizant of the impact of diagnosis on patient care, even in ambiguous situations

Demonstrates knowledge of the limitations of techniques and interpretation

Appropriately and professionally discusses with requesting provider any IOC/FS that is contraindicated

Responds appropriately to the concerns of the surgeon

Given discussion of the case with the attending staff member(s), communicates appropriately with surgeon, asking appropriate questions that influence diagnosis

Communicates limitations of techniques and interpretation to clinicians

Proficient in the performance of IOC/FS

Able to manage competing tasks, especially in time sensitive situations

Comments:

Suggested Evaluation Methods: Direct observation, Narrative, Feedback from clinical colleagues (360 evaluations), Retrospective peer review, Portfolio, Quality management


PC7: Procedures: If program teaches other procedures (e.g., bone marrow aspiration, apheresis, fine needle aspiration biopsy, ultrasound guided FNA, etc.) (AP/CP)

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

Recognizes the role of the procedure

Participates in simulated experience in the procedure, including slide preparation and staining, if applicable

Observes and assists on the procedure

Observes or participates in providing support to other service providers performing the procedure

Is aware of potential complications of the procedure and need to obtain informed consent

Discusses with pathology attending staff member(s) any requests that are contraindicated, obtains informed consent, and is able to assess specimen and procedure adequacy

Performs a "time-out" according to standard procedures; performs the procedure; procures adequate specimens, if applicable

Provides an accurate adequacy assessment and triages specimens for appropriate ancillary studies, if applicable

Obtains informed consent

Recognizes and understands the management of complications of the procedure

Appropriately and professionally documents procedure and discusses with clinical team and manages complications

Able to perform the procedure with minimal supervision

Understands indications for and/or performs ultrasound guided Fine needle aspiration biopsy (FNAB) and/or core needle biopsy, if applicable

Provides appropriate provisional assessment

Manages complications of the procedure or refers to the appropriate health care professional

Proficient in the performance of the procedure

Comments:

Suggested Evaluation Methods: Direct observation, Simulation


MK1: Diagnostic Knowledge: Demonstrates attitudes, knowledge, and practices that incorporate evidence-based medicine and promote life-long learning (AP/CP)

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

Identifies the resources for learning in pathology

Assimilates medical knowledge in pathology from various learning sources

Demonstrates textbook- level diagnostic knowledge for pathology

Performs scientific literature review and investigation of clinical cases to inform patient care (evidence-based medicine) and improve diagnostic knowledge of pathology

Applies and synthesizes medical knowledge from scientific literature review and investigation to inform patient care (evidence- based medicine)

Presents and discusses cases

Demonstrates competence in diagnostic knowledge of pathology

Contributes to medical knowledge of others and participates in life-long learning through literature review, Continuing Medical Education [(CME), and Self- Assessment Modules (SAMs)

Demonstrates proficiency in knowledge of pathology

Comments:

Suggested Evaluation Methods: Direct observation, Pre- and post-test, Rotation exams, Narrative, 360 evaluation, Board examination, Maintenance of certification/SAMs,

Resident In-Service Examination (RISE) and Pathologist Recertification Individualized Self-Assessment Exam (PRISE)


MK2: Teaching: Demonstrates ability to interpret, synthesize, and summarize knowledge; teaches others (AP/CP)

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

Participates in active learning Understands and begins to acquire the skills needed for effective teaching

Teaches medical students, as needed

Teaches peers as needed Teaches across departments and at all levels, including to clinicians, patients, and families

Models teaching across departments and at all levels, including for clinicians, patients, and families

Comments:

Suggested Evaluation Methods: Direct observation, 360 evaluations, Teaching evaluations, Student performance on exams, Simulations, Conference presentation

evaluation portfolio


MK3: Procedure: Autopsy: Demonstrates knowledge and practices that enable proficient performance of a complete autopsy (analysis and appraisal of findings, synthesis and assembly, and reporting) (AP)

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

Understands the principles of confidentiality, universal precautions, chemical hazards, and personal protective equipment

Understands the value of an autopsy

Properly identifies the decedent and verifies consent and limitations to extent of the autopsy

Able to perform all seven aspects of a routine autopsy

Concisely reviews and presents clinical records/history; contacts the clinical team in advance of the case and summarizes questions posed by the clinical team

Is aware of reporting regulations, such as legal jurisdiction, statutes regarding authorization to perform autopsy (medical examiner), device reporting, communicable diseases

Able to plan and perform complex/difficult cases

Assists in preparation of presentations for morbidity and mortality (M&M), Clinical Pathologic Conference (CPC), or other conferences

Understands chain of custody, the elements of scene investigation, trace evidence, and court testimony

Performs uncomplicated gross dissection within four hours

Presents results at M&M, CPC, or other conferences, and effectively answers clinical questions

Assesses and applies chain of custody, interprets the elements of scene investigation, trace evidence, and court testimony

Proficient in the performance of a complete autopsy and in reporting the results in a timely manner

Proficient in the presentation of results at M&M, CPC, or other conferences, and in answering clinical questions

Proficient in the discussion of the chain of custody, and interpretation and assessesment of the elements of scene investigation, trace evidence, and giving court testimony

Comments:

Suggested Evaluation Methods: Direct observation; Feedback from clinical colleagues (360 evaluations), Narrative, Portfolio review, Quality management; Peer evaluation


SBP1: Patient safety: Demonstrates attitudes, knowledge, and practices that contribute to patient safety (AP/CP)

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

Understands the importance of identity and integrity of the specimen and requisition form and verifies the identity

Understands the risk inherent in hand-overs

Consistently checks identity and integrity of specimen

Independently obtains clinical information when needed

Explores other resources such as EMR and radiology

Handles deviations from policies (waivers) with supervision

Performs hand-overs in an appropriate manner, according to guidelines (e.g., Situation- Background-Analysis- Recommendation [SBAR] or local guidelines)

Trouble-shoots pre- analytic problems, as needed, with minimal supervision, including deviations from policies (waivers)

Follows patient safety policies and accreditation requirements

Trouble-shoots patient safety issues (including pre-analytic, analytic, and post-analytic), as needed, without supervision

Models patient safety practices

Writes and implements policies on patient safety, as needed

Completes an advanced MOC patient safety module

Comments:

Suggested Evaluation Methods: Direct observation, Narrative, QA reports (misidentification rates, amended report rates), Transfusion committee

results/work-ups, Documentation provided


SBP2: Lab Management: Regulatory and compliance: Explains, recognizes, summarizes, and is able to apply regulatory and compliance issues (AP/CP)

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

Knows that laboratories must be accredited

Can define appropriate disclosure of protected health information (PHI) as defined by the Health Insurance Portability and Accountability Act (HIPAA)

Knows accrediting agencies of the laboratory

Is aware of requirements for institutional review for human experimentation (research) and biospecimen donation

Understand and apply policies and procedures inPHI as defined by HIPAA

Understands the components of lab accreditation and regulatory compliance (Clinical Laboratory Improvement Ammendments [CLIA] and others), either through training or experience

Confirms institutional review board approval prior to biospecimen procurement

Completes laboratory inspector training

Understands ICD9 (ICD10) coding and the need to document appropriately in reports

Teaches allied health professionals and clerical staff as necessary about the policies and procedures of PHI as defined by HIPAA

Understands the components and processes for credentialing and privileging

Participates in an internal or external laboratory inspection

Able to correctly use Current Procedural Terminology (CPT) and ICD9 (ICD10) codes for billing purposes; understands elements of a compliance plan

Assists colleagues as needed with policies and procedures of PHI as defined by HIPAA

Participates in and complies with ongoing and focused competency assessment

Participates in or leads internal or external laboratory inspections

Participates in institutional review process, as needed

Creates and follows a compliance plan

Uses best practices for billing compliance

Comments:

Suggested Evaluation Methods: Direct observation, Portfolio, Simulation, Examination, Team leader performance evaluation, Portfolio review, Quality management; Peer evaluation


SBP3: Lab Management: Resource Utilization (personnel and finance): Explains, recognizes, summarizes, and is able to apply resource utilization (AP/CP)

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

Interprets an organizational chart and is aware of employment contracts and benefits

Describes a budget

Knows the personnel and lines of reporting in the laboratory

Recognizes different budget types (i.e., capital vs. operating budget)

Understands the basics of pathology practice finance (e.g., Part A and Part B, Centers for Medicare & Medicaid Services [CMS])

Understands and describes the process of personnel management and employment laws (e.g., interview questions, Family and Medical Leave Act, termination policies)

Understands key elements of hospital and laboratory budgets

Creates a basic job description and participates in employee interviews/performance evaluation (real or simulated experiences)

Participates in a budget cycle exercise (draft, defend, and propose logical cuts and/or additions)

Manages personnel effectively

Develops and manages a laboratory budget

Comments:

Suggested Evaluation Methods: Direct observation, Portfolio, Simulation, 360 evaluation, Analysis of resident evaluations (meeting, employee interview, difficult

conversations)


SBP4: Lab Management: Quality, risk management, and laboratory safety: Explains, recognizes, summarizes, and is able to apply quality improvement, risk management and safety issues (AP/CP)

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

Participates in basic safety training (e.g., Occupational Safety and Health Administration [OSHA], blood borne pathogen, personal protective equipment)

Participates in laboratory specific safety training (e.g., sharps disposal, proper equipment utilization)

Understands when and how to file an incident or safety report

Understands the concept of a laboratory quality management plan

Interprets quality data and charts and trends

Understands continuous improvement tools, such as Lean and Six Sigma

Understands serious reportable events (SREs) and appropriate reporting, and participates in root cause analysis (RCA)

Demonstrates a knowledge of proficiency testing and its consequences

Attends and participates in quality improvement meetings

Has completed a quality improvement project

Reviews and analyzes proficiency testing results

Participates in department and hospital-wide quality, risk management, and safety initiatives

Utilizes continuous improvement tools, such as Lean and Six Sigma

Manages laboratory quality assurance and safety

Comments:

Suggested Evaluation Methods: Direct observation, Portfolio, Simulation, Narrative, Examination, 360 evaluations


SBP5: Lab Management: Test utilization: Explains, recognizes, summarizes, and is able to apply test utilization (AP/CP)

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

Is aware of the test menu and rationale for ordering

Organizes basic data for utilization review

Identifies key elements of ordering practices

Able to understand appropriate ordering or inappropriate ordering and over-utilization

Able to interpret charts and graphs that demonstrate utilization patterns

Intervenes in inappropriate or over-utilization situations

Able to create charts and graphs that demonstrate utilization patterns (simulated or real experiences)

Maintains a portfolio that includes experience in test utilization reviews and interventions that drive change

Demonstrates a broad portfolio of analyses for utilization reviews in complex scenarios and team management to drive change in areas both within and outside of the department

Comments:

Suggested Evaluation Methods: Direct observation, Portfolio, 360 analysis, Simulation


SBP6: Lab Management: Technology assessment: Explains, recognizes, summarizes, and is able to apply technology assessment (AP/CP)

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

Understands the value of new technology

Understands the need for a process in implementing new technology

Aware of cost-benefit analysis for new technology

Understands and describes the process of implementing new technology

Able to perform a cost- benefit analysis

Participates in new instrument and test selection, verification, implementation, and validation (including reference range analysis) and maintains a portfolio of participation in these experiences

Acts as primary assessor for new technology and is able to lead efforts to optimize test utilization and resource management

Comments:

Suggested Evaluation Methods: Direct observation, Portfolio, Simulation


SBP7: Informatics: Explains, discusses, classifies, and applies clinical informatics (AP/CP)

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

Demonstrates familiarity with basic technical concepts of hardware, operating systems, and software for general purpose applications

Understands lab specific software, key technical concepts and subsystems on interfaces, workflow, barcode application, automation systems (enterprise systems architecture)

Applies informatics skills as needed in project management (data management, computational statistics)

Participates in operational and strategy meetings, apprentices troubleshooting with IT staff, applies informatics skills in laboratory management and integrative bioinformatics (able to aggregate multiple data sources and often multiple data analysis services)

Is proficient in medical informatics systems

Able to assess and purchase a laboratory information system for anatomic and/or clinical pathology laboratories

Able to utilize medical informatics in the direction and operation of the laboratory

Comments:

Suggested Evaluation Methods: Direct observation, 360 evaluation, Portfolio data


PBLI1: Recognition of errors and discrepancies: Displays attitudes, knowledge, and practices that permit improvement of patient care from study of errors and discrepancies. (AP/CP)

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

Acknowledges and takes responsibility for errors when recognized

Recognizes limits of own knowledge

Initiates self-reflection process, (e.g., as evidenced in self-assessment interviews with program director)

Reflects upon errors in a group setting (such as M&M type conference setting)

Participates in root cause analysis (RCA)

Demonstrates significant awareness of own blind spots

Participates in or leads communication of error/discrepancies to clinicians

Models use of errors and discrepancies to improve practice

Provides immediate communication of error/discrepancies to clinicians

Comments:

Suggested Evaluation Methods: Self-assessment (written and verbal), Direct observation, Narrative


PBLI2: Scholarly Activity: Analyzes and appraises pertinent literature, applies scientific method to identify and interpret evidence-based medicine and apply it clinically (AP/CP)

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

Utilizes and applies basic texts

Uses presentation software, online literature databases, and searches as needed

Demonstrates working knowledge of basic statistical analysis

Develops knowledge of the basic principles of research (demographics, Institutional Review Board [IRB], human subjects), including how research is conducted, evaluated, explained to patients, and applied to patient care

Critically reads and incorporates the medical literature into presentations and lectures

Applies knowledge of the basic principles of research

Adds to a portfolio of scholarly activities, which may include manuscript preparation, abstract presentation at a local, regional or national meeting, or other scientific presentation

Critically examines literature for study design and use in evidence-based clinical care

Identifies gaps in the currently available knowledge

Has a well developed portfolio of scholarly activities

Proficient in critical evaluation of the literature and participates in life-long learning

Comments:

Suggested Evaluation Methods: Direct observation and evaluation of presentations by participants, Portfolio, Examination


PROF1: Licensing, certification, examinations, credentialing: Demonstrates attitudes and practices that ensures timely completion of required examinations and licensure (AP/CP)

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

Completes and passes Step 2CK and 2CS of United States Medical Licensing Examination (USMLE)

Completes and passes Step 3 of USMLE

Performs at expected level on objective examinations

Begins assembling portfolio of experiences, including case log and participation in administrative tasks

Performs at expected level on objective examinations

Demonstrates expanded portfolio and reviews with program director at semi- annual evaluation

Applies for full and unrestricted medical license

Demonstrates complete portfolio and reviews with program director at semi- annual evaluation

Obtains full and unrestricted medical license

Board-eligible/Board- certified and begins to participate in maintenance of certification (SAMS, etc.)

Maintains portfolio

Comments:

Suggested Evaluation Methods: Documentation provided


PROF2: Professionalism: Demonstrates honesty, integrity, and ethical behavior (AP/CP)

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

Behaves truthfully and understands the concepts of ethical behavior, occasionally requiring guidance; seeks counsel when ethical questions arise

Understands the concepts of respect, compassion, and empathy

Is truthful, acknowledges personal near misses and errors, and puts the needs of patients first

Engages in ethical behavior

Observes patient confidentiality

Manifests sensitivity to patient's fears and concerns

Demonstrates respect, compassion, and empathy to all

Demonstrates truthfulness to all members of the health care team

Identifies, communicates, and corrects errors

Demonstrates respect, compassion, and empathy, even in difficult situations

Exemplifies truthfulness to all members of the health care team

Serves as a role model for members of the health care team in accepting personal responsibility

Puts the needs of each patient above his or her own interests

Promotes respect, compassion, and empathy in others

Models truthfulness to all members of the health care team; is viewed as a role model in accepting personal responsibility by members of the health care team; and always puts the needs of each patient above his or her own interests

Models respect, compassion, and empathy, in complex situations

Comments:

Suggested Evaluation Methods: Direct observation, 360 evaluation


PROF3: Professionalism: Demonstrates responsibility and follow-through on tasks (AP/CP)

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

Completes assigned tasks on time

Dependably completes assigned tasks in a timely manner

Assists team members when requested

Respects assigned schedules

Anticipates team needs and assists as needed

Anticipates team needs and takes leadership role to independently implement solutions

Exemplifies effective management of multiple competing tasks, including follow-through on tasks

Is source of support/guidance to other members of health care team

Comments:

Suggested Evaluation Methods: Direct observation, 360 evaluation, Portfolio data (e.g., autopsy TAT)


PROF4: Professionalism: Gives and receives feedback (AP/CP)

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

Receives feedback constructively

Accepts feedback constructively and modifies practice in response to feedback

Able to provide constructive feedback

Exemplifies giving and receiving constructive feedback

Encourages and actively seeks feedback to improve performance

Models giving and receiving constructive feedback

Encourages and actively seeks feedback to improve performance

Comments:

Suggested Evaluation Methods: Direct observation, 360 evaluation, Role-play or simulation, Resident experience narrative

PROF5: Professionalism: Demonstrates responsiveness to each patient’s unique characteristics and needs (AP/CP)

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

Respects diversity, vulnerable populations, and patient autonomy

Embraces diversity and respects vulnerable populations

Is aware of potential for bias or cultural differences to affect clinical care

Demonstrates cultural competency

Identifies and avoids biases, and recognizes cultural differences that may affect clinical care

Exemplifies cultural competency

Identifies and avoids biases, and recognizes cultural differences that may affect clinical care

Models cultural competency

Works with peers to avoid biases

Recognizes cultural differences that may affect clinical care

Comments:



PROF6: Professionalism: Demonstrates personal responsibility to maintain emotional, physical, and mental health (AP/CP)

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

Is aware of importance of emotional, physical, and mental health and issues related to fatigue/sleep deprivation

Exhibits basic professional responsibilities, such as timely reporting for duty rested, readiness to work, and being appropriately dressed

Manages emotional, physical, and mental health and issues related to fatigue/sleep deprivation

Recognizes signs of impairment, and seeks appropriate help when needed

Manages emotional, physical, and mental health and issues related to fatigue/sleep deprivation, especially in stressful conditions

Recognizes signs of impairment in self and others, and facilitates seeking appropriate help when needed

Anticipates and avoids behaviors that might lead to impairment

Accesses institutional resources to address impairment, and initiates seeking appropriate help when needed

Comments:



ICS1: Intra-departmental interactions and development of leadership skills: Displays attitudes, knowledge, and practices that promote safe patient care through team interactions and leadership skills within the laboratory (AP/CP)

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

Demonstrates respect for and willingness to learn from all members of the pathology team

Is aware of the significance of conflict in patient care

Works effectively with all members of the pathology team

Attends laboratory, departmental, or institutional committee meetings

Aware of the mechanisms for conflict resolution

Participates in a cytopathology team with cytopathologists, cytotechnologists and lab assistants, or surgical pathology team with surgical pathologists, histotechnicians and lab assistants or clnical pathology team with the pathologist, clinical laboratory scientists and lab assistants

Understands own role on the pathology team, and flexibly contributes to team success through a willingness to assume appropriate roles as needed

Understands the basics of running a meeting

Utilizes mechanisms for conflict resolution and helps to defuse and ameliorate conflict

Participates in groups to accomplish goals

Helps to organize the pathology team to facilitate optimal communication and co- education among members

Demonstrates the ability to lead and run an effective meeting

Participates effectively in conflict resolution

Demonstrates ability to lead groups to reach a consensus and accomplish goals

Leads the pathology team effectively

Models respect for others

Models effective conflict prevention and resolution skills

Comments:

Suggested Evaluation Methods: Direct observation, 360 evaluation, Narrative

ICS2: Inter-departmental and Health care Clinical Team interactions: Displays attitudes, knowledge, and practices that promote safe patient care through interdisciplinary team interactions (AP/CP)

Has not Achieved

Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

Recognizes the importance of clinical input in formulating a differential diagnosis and composing a final diagnosis

Is aware that multi-disciplinary conferences are used to further appropriate patient care

Is aware of pathologist’s role in the clinical team

Understands utility of communication with other members of the clinical team

Participates through observation and active interaction with clinicians to obtain relevant clinical and/or radiologic data

Attends multidisciplinary conferences

Recognizes the importance of timely production of a final diagnosis and the role it plays in patient care

Appropriately triages requests for information from the clinical team

Is aware of the limitations of own knowledge

Assesses, analyzes, and interprets pathology reports and is able to discuss findings in consultation with clinical colleagues

Prepares and presents cases at multidisciplinary conferences

Responds to inquiries from the clinical team to contribute to patient care

Effectively communicates clinically significant or unexpected values, including critical values

Is aware of the limitations of medical knowledge

Routinely interfaces with clinical colleagues to formulate a narrow differential diagnosis and arrive at a final diagnosis

Can lead multidisciplinary conferences

Knows how subtleties may impact or alter patient care; recognizes and uses nuances in the proper wording in the discussion of pathology findings

Participates in or leads communication with the clinical team to contribute to patient care

Communicates the limitations of medical knowledge

Fully participates as a member of the health care team, and is recognized as proficient by peers and clinical colleagues

Organizes and is responsible for multidisciplinary conferences

Serves as a consultant to the health care team

Comments:

Suggested Evaluation Methods: Direct observation, 360 evaluation, Narrative

CONFERENCE SCHEDULE AND RESPONSIBILITIES

CONFERENCE SCHEDULE

Monday 12:00pm Seminars in Laboratory

Medicine* Weekly CLB Room 1021

Tuesday

7:00am AP Didactic Conference/Unknown Surgical Pathology Slide Conference *

Weekly

Totten Room, Scaife 618

11-12pm Hematopathology Flow Conference**

~Every other week (see schedule)

CLB Room 9018

12:00pm Hematopathology Journal Club*, ***,###

Every other week


12:00pm Patient Safety & Risk Management in Hematopathology Conference*, ###

Every other week

PUH G323

Wednesday

7:00 am CP Didactic Conference* Weekly CLB Room 1021

8:30am Hematopathology Conference (case presentation)* ***, ###

1st-3

rd, 5

th Week

of the month Totten Room, Scaife 618

8:30am Molecular/ Hematopathology Conference

4th week of the

month


10:30am Hematology Lab Operations++ Bi-Weekly (see schedule)

CLB 6th Floor Room

6032

12:00pm

Department Research Seminar+

Weekly PUH 11th Floor

12:00pm Cutaneous Lymphoma Journal Club

Last Wednesday of the Month

Medical Arts Building 3708 Fifth Avenue 5th Floor, Suite 500.79 (Conference Room A - 500.81)

Thursday

12:00pm Anatomic Pathology Grand Rounds *

Weekly Room 1104 A & B Scaife Hall

4:00pm CHP Tumor Board+++, ***

Leukemia Conference 1

st Thursday of

the month Rangos Res. Bldg - Lawrenceville

Friday 1:00pm-2:30pm

Molecular QA Conference Weekly CLB 8th Fl conference

room

* Attendance for residents required either based on this rotation or departmental expectations.

** Attendance at this conference is strongly encouraged for trainees (but not required).

*** The trainees will be expected to present at these conferences.

**** Attendance is strongly encouraged when hematopathology cases are being presented (be sure you are getting email notifications).

@ Attendance not expected.

+ Attendance optional.

++ Attendance is required for residents on laboratory medical rotation.

+++ Attendance is expected for trainees doing pediatric hematopathology.

# See description concerning attendance obligations.

## Attendance required when on laboratory hematology rotation and encouraged when on other parts of hematology rotation. One presentation required (see schedule).

### Attendance required for fellows

RESIDENT AND FELLOW CONFERENCE RESPONSIBILITIES

MONDAY

12:00PM (Weekly)

Seminars in Laboratory Medicine are case presentations/lectures by residents, fellows and faculty. See Conference Schedule from Laboratory Medicine Office for topics.

TUESDAY

7:00AM

The AP Didactic Conference/Unknown Surgical Pathology Slide Conference takes place on Tuesdays from 7:00 to 9:00 AM in the Totten Room. The slides and clinical history for the conferences when they occur will be available at PUH, Shadyside and Magee for preview at least one week prior to the conference. The schedule is available on the resident website (http://residents.pathology.pitt.edu/default.aspx). Fellows may attend; however it is not required and hematopathology duties take precedence. Breakfast is served.

8:30AM SHY Adult Bone Marrow Review takes place Tuesdays from 8:30 – 9 am. A few cases selected

by the Hematology/oncology attending and fellow are presented via teleconference using Go to Meeting (complete instructions posted in G304). The cases will be presented by the attending pathologist on BM service 3, or the hematopathology fellow on BM service 2 with the BM3 attending pathologist serving as a mentor.

9:15AM

Continuing Education in Clinical Chemistry and Hematology Conference takes place Tuesdays at 9:15 -10:15am (following the residents' lectures). The location is usually CLB room 1021. Each resident on the laboratory hematology rotation will present once. The sessions are targeted toward technologist education. Discussion between pathologists/trainees is encouraged. Periodic updating of important basic concepts is welcome. Please seek input from Dr. Contis when planning your hematology presentation.

11:00AM (several times/month)

The Flow Cytometry Conference is a time when interesting flow cytometry cases selected by the technologists are reviewed and discussed by one of the hematopathologists. Some conferences are used for didactic presentations on a specific topic. Generally, other hematopathologists, residents and fellows attend. No preparation is required. See schedule for dates of conference. (CLB, Room 9018)

12:00PM

Approximately twice per month, residents doing Hematopathology will be asked to select one (1) current journal article for presentation at our Journal Club (see separate schedule). The selection should be of interest to the presenter and others in the group and needs to be approved by the faculty member or fellow responsible for that date (see schedule for dates and trainee/faculty assignments). If requested, the faculty member can also offer suggestions for appropriate articles or offer additional advice in making a selection. The faculty person or fellow will also choose and present an article. The articles should be emailed to the hematopathology secretary, Jessica Klimkowicz, no later than Thursday preceding the Journal Club.

In terms of presentation, it is important to provide enough background information to help explain why the study was done and /or may be important and how it relates to what is already

http://residents.pathology.pitt.edu/default.aspx

known. Any detailed discussion of methodology that may be required should be done when the results are presented. When presenting the results, it is important to go over the various tables and figures in the paper and also point out any problems that may be presented in the data or methodology. Finally, the ultimate significance of the study given the results found should be discussed. PowerPoint presentations are not at all necessary and are discouraged!

Everyone attending should also be prepared to comment on the above issues so that a lively

discussion will ensue. On all other Tuesdays, there will be a Patient Safety and Risk Management Conference (see

separate schedules). Cases are presented and discussed that could potentially raise patient safety and risk management issues. For example, cases that are particularly prone to diagnostic errors or cases of entities seen so infrequently that pathologists might not be familiar with them would be of particular interest. Cases where there have been any types of errors made within or outside our institution would also be of particular value. Trainees, along with faculty members, may bring cases to show.

WEDNESDAY

7:00AM

CP Didactic Conference is a set of lectures covering all of laboratory medicine, some pertinent to hematopathology. The schedule is available on the resident website. (http://residents.pathology.pitt.edu/default.aspx).

8:30AM

The Hematopathology Conference is entirely the responsibility of our division. The purpose is to provide a forum to go over morphologic, immunophenotypic, karyotypic, and genotypic issues together with their clinical correlates. We present 5 cases each week at conference, ideally 3-bone marrow (including Children’s cases) and 2 lymph nodes. The conference responsibilities include:

Trainees on the adult bone marrow service will consult with faculty signing out marrows no later than Friday and choose 3 interesting and /or educational marrows. As at least one pediatric marrow should be presented if there is a trainee on the service, trainees on the adult marrow service need to consult with the pediatric service to be sure that 3 bone marrows/PB/ATL cases are being presented. Please do not add additional cases if there are already 5.

A. After cases are selected, please sign-up by giving name and number to the bone marrow

technologist or leaving a voicemail message on the Audix line (802-3273). NAMES MUST BE SUBMITTED BY THE END OF MONDAY.

The trainees will take images using one of the digital camera set-ups in the Division of Hematopathology (room G304 conference room or G323 lymph node sign-out room) and find out the case history from the physician or the chart. The images should be imported into a PowerPoint presentation. At the conference, the trainees will present the case including a brief history, any prior material and any ancillary studies at the conference. In addition, some interesting aspects of the case may be discussed briefly (e.g. implications of an unusual morphologic appearance, significance of unusual phenotype). Don’t give a lecture. Cytogenetics will be presented by the cytogenetics laboratory faculty or by a trainee rotating in Cytogenetics. Fellows are expected to present their own cytogenetic findings as long as the laboratory emails them the karyotypes/FISH images to show and a

http://residents.pathology.pitt.edu/default.aspx

cytogeneticist can assist when needed. Genotypic results are usually presented by the Division of Molecular Diagnostics. If no trainee is on the service, the cases are presented by the faculty member. Case presentations including all ancillary studies should be less than 8 minutes to allow time for discussion.

B. Trainees on the lymph node service will consult with the faculty member signing out lymph

nodes and select two lymph node cases to present. In the absence of appropriate current cases, older educational cases may be selected. The trainees will take images of the case and if at all possible get the history from the chart or physician. At the conference, using PowerPoint the trainee will present the case including a brief history, the pathology and any ancillary studies.

C. Remember case presentations must be relatively brief, to the point and interesting both to pathology trainees and clinicians. If possible try to present cases in an interactive fashion. (Totten Room, Scaife 618)

D. If there is >1 trainee on a service, the presenting obligations should be shared.

Guidelines for PowerPoint Presentations 1. Keep the presentation simple. Your time is better spent reading about the case

rather than having multicolored images flying around. 2. Try to limit the number of images shown- make sure that each image makes a point. 3. Photomicrographs should occupy the entire screen. 4. Please use images that are in focus. 5. No more than two flow histograms should be on a single screen (or just use the

electronic overhead projector). 6. Up to 4 immunostains may be presented in a single screen. It is unnecessary to

illustrate all immunostains- you need to choose critical ones or ones that are necessary to make your point. For example, please don’t show a series of 5 negative stains.

7. Laboratory results can either be discussed or, if presented on a screen, must have not only the numerical results, but also the units and preferably the normal ranges. The lab results that are presented visually do not need to include every single laboratory test that was done on the patient.

8. In at least most cases, there is no need to present a written bone marrow differential.

12:00PM

Trainees are encouraged, but not required to attend the Departmental Research Conference. 12:00PM

UPMC-Shadyside Tumor Board. Cases are presented by the hematopathology fellow or if necessary by a hematopathology faculty member at the request of a clinician (detailed procedure on page 22) (Shadyside West Wing Auditorium). Residents do not attend.

THURSDAY

8:00AM

A Pediatric Bone Marrow Case Conference is held via teleconference to the Children’s Hospital, Lawrenceville except for the first Thursday of the month. This is attended

primarily by the pediatric hematology/oncology fellows, and the pathology trainees on the pediatric bone marrow service. The bone marrow technologists will collect the cases from the prior week to be presented by the attending hematopathologist on service. Fellows may be expected to present the cases. Complete instructions for using Go-To-Meeting are in the pediatric bone marrow signout room G304,

12:00PM

Residents doing hematopathology are expected to attend Anatomic Pathology Grand Rounds.

4:00PM Pediatric Leukemia Tumor Board is held the first Thursday of the month from 4:00 to 5:00 in

Conference Rooms B123 and B124, Floor B, at Children’s Hospital of Pittsburgh. The hematopathologists and bone marrow technologists are notified by e-mail the week of the conference as to which cases are to be presented. The bone marrow technologists will collect the cases for the trainees. The trainees will capture images and prepare a PowerPoint presentation. The presentations should be brief and succinct and include 1 slide of peripheral smear, 1-2 slides of aspirate, and 1-2 slides of biopsy as well as any pertinent cytochemical or immunohistochemical stains. Flow images can also be presented – please check with attending regarding specific images to present. Pertinent results from the cytogenetics and/or molecular studies should be summarized in 1-2 slides. The presentation should be approved by the attending prior to presentation.

Additional information regarding Shadyside Tumor Board Conference

Wednesday Noon

Contact Person SHY: Melissa Forkey 412-648-6466

Contact Person PUH: Celina Fortunato 412-647-0263

1. UPMC – Shadyside will call the UPMC – Presbyterian bone marrow lab at 647-0263 with a list of patient names NO LATER THAN the Friday preceding the conference (preferably earlier).

2. The Bone Marrow Technologist will inform the presenter.

a. First inform the 2nd year fellow if there is one. If the 2nd year fellow cannot present (i.e. on a rotation that precludes their availability), the fellow must inform the bone marrow technologists immediately. Go to step b.

b. Next, inform the 1st year fellow. If the 1st year fellow cannot present (i.e. on a rotation that precludes their availability), the fellow must inform the bone marrow technologist immediately. Next inform the second 1st year fellow if there is one. If there is more than one second year fellow or more than one first-year fellow, please ask the one not on a diagnostic signout service first to do the tumor board (unless they are on another service that would preclude their being able to attend). If this fellow also cannot present, go to step c.

c. If no fellow can present, the bone marrow technologist will inform the pathologist on the lymph node service for the week it is to be presented.

This way the bone marrow technologist will know who exactly will be presenting the conference. 3. The bone marrow technologist will pull the slides and print the reports. 4. If surgical pathology cases are requested, the bone marrow technologist will notify

Melissa Forkey who will make other arrangements for the cases to be presented by surgical pathologist.

5. The bone marrow technologist will inform the person responsible for the

presentation – prior to the weekend – that the cases are ready. 6. The bone marrow technologist will record on the log sheet that the cases are ready

and the presenter is notified. The bone marrow technologist will call Melissa Forkey and inform her who will be presenting the case.

Pediatric Hematopathology and General/Special

Hematology Laboratory Experience

Pediatric Hematopathology and General/Special Hematology Laboratory Experience (3 weeks)

Trainees should report to the pathologist signing out CHP bone marrows. The pathologist covering the general hematology laboratory (“ATL” service) is usually the same person; if this person is different from the one signing out CHP bone marrows, then contact him or her also. Also, trainees should contact Dr. Contis regarding their continuing education conference presentation at the beginning of their rotation. Residents also will discuss with Dr. Contis or her designee how to best apportion their time in the laboratory and how to gain in-laboratory experience with the technologists.

Pediatric Hematopathology Experience

1. Review Blood Cell Morphology. (Published by the ASCP). RBC, WBC, Normal and Abnormals

(Binders with CDs available in G304 and slides are also on resident’s shared drive, under “CP

Didactic Lectures\Previous CP Didactic Lectures\Hemepath\ASCP Hematology Images.” Each set

is a separate PowerPoint file and the key and reading material for all 6 sets of images are in the

PDF).

2. In the first week, touch base with the lead technologist Celina Fortunato to schedule a

teaching session with the bone marrow technologists (typically Tuesday afternoon is best)

to review peripheral blood and bone marrow aspirate smears

3. Pediatric Bone Marrow Sign out.

A. Preview and sign out cases with hematopathology faculty in a fashion analogous to

procedures followed with adult bone marrows.

Meet with faculty on service to coordinate these activities.

See also “Policy for sign-out of CHP marrows that have biopsies”.

4. Review of specimens from Automated Testing Laboratory and Flow Cytometry Laboratory

A. Preview and sign out pediatric and adult abnormal peripheral blood films and body fluid slides

sent for review with ATL faculty hematopathologist. Gather relevant clinical and pathology

information (such as cytology results) prior to sign-out.

B. If there is a case with interesting findings, please give the slide and copy of the ATL review

sheet to Dr. Djokic in order to contribute to the study sets.

5. Review of selected cases of Hemoglobinopathies with the CAP textbook

Trainees should pre-review the HPLC tracings that are being faxed weekly to our division and they should contact Dr. Dobrowolski and meet with him once at Children’s Hospital (CHP) to review the cases with him.

6. Review of educational materials

A. Swerdlow SH, Collins RD Pediatric Hematopathology, Churchill Livingstone, 2001.

B. Nathan, DG and Orkin, SH, Nathan and Oski’s Hematology of Infancy and Childhood, 7th

Edition, WB Saunders, 2009.

C. Penchansky L, Pediatric Bone Marrow, Springer, 2004.

D. Glassy EF. Color Atlas of Hematology, CAP 1998

E. Peripheral smear and fluid slide study sets are available for checkout from Office Secretary –

G306.

F. Chromogram information for hemoglobinopathy information (in supplemental materials)

G. Bain BJ. Haemoglobinopathy Diagnosis, 2nd ed. Blackwell, 2006.

H. Schuman GB, Friedman SK. Wet Urinalysis, ASCP, 2003.

I. Galagan, K. Color Atlas of Body Fluids: An Illustrated Field Guide Based on Proficiency

Testing.

J. Proytcheva, M.A. (Ed), Diagnostic Pediatric Hematopathology, 2011.

7. Review results of ancillary procedures performed on marrows you have reviewed and read

addenda faculty have issued.

Policy for sign-out of CHP marrows that have biopsies

1. Hematopathology signs out biopsies on hematologic disease cases including non-Hodgkin

lymphomas. CHP surgical pathology signs out the biopsies on tumor cases.

2. On all cases with a biopsy, the histologic section must be reviewed by the hematopathologist

even if it is not a case where the hematopathologist is signing out the biopsy. This is to ensure

that it does not conflict with the aspirate smear evaluation.

3. In all cases with a biopsy, where CHP is signing out the biopsy the hematopathologist should

correlate with the CHP pathology report to make sure that the two diagnoses will not conflict. In

some cases, this may involve contacting the CHP pathologist and jointly reviewing the case.

Policy for Assignment of Marrow Cases without Biopsies

Marrow sign-out is the responsibility of the faculty/trainee on the service when the marrow biopsy typically would come out. However, all cases done on Friday must be pre-reviewed by those on the service that day. In addition, all marrows, pediatric or adult, with or without flow cytometry that do not have a biopsy and are received before noon on a Friday, must be signed out by those on the service that week. They are not the responsibility of those on the following week. Children’s bone marrow aspirates with biopsies for metastatic tumor evaluation received on Friday will be the responsibility of the pathologist on service the following week, even though we are only signing out the aspirate.

General/Special Hematology Experience

1. Meet with Dr. Contis or her designee to review plan for completion of checklist that follows.

2. Plan laboratory presentation (see instructions on Continuing Education in Clinical Chemistry

and Hematology).

3. See checklist for specific activities and educational resources.

General/Special Hematology Laboratory Experience Checklist

This checklist indicates the areas that need to be covered during the general/special laboratory experience and the specific activities that are to be performed. This should occupy approximately half your time when combined with pediatric hematopathology (as in core resident/fellow rotation). Check boxes to the left of specific activities when the indicated activities are completed This checklist is also included separately and must be signed by the resident/fellow and turned in to Dr. Swerdlow’s office at the completion of the rotation.

1. General Activities

Review a spectrum of abnormal peripheral blood and body fluid results. These should include:

o Macrocytic and microcytic anemias

o RBC changes in autoimmune hemolytic anemia

o Thrombocytopenia and inherited platelet disorders

o Granulocytosis and granulocytopenia

o Lymphocytosis

o Blasts in the peripheral blood or cerebrospinal fluid

o Abnormal cytoplasmic inclusions in WBC & RBC as available, either as review specimens or in

the study sets

o Metastatic tumor

o Infectious disease: malaria, babesiosis, anaplasmosis

If cases of each of the above are not available and you are in your last week, be sure to review teaching slides or other resources (ask Dr. Contis or designee for help if required). At the end of the 3-week rotation, meet with Dr. Contis to go over your list.

Follow up on patients whose abnormal peripheral bloods and body fluids you have reviewed to

determine the significance of the abnormality on diagnostic and therapeutic decision making and

ultimate clinical outcome.

Keep a list of the following (include relevant clinical information that you have obtained for each

patient):

The laboratory tests (routine and special) that you have observed (or reviewed following

returns by the reference laboratories).

The abnormal peripheral blood films and body fluid smears that you have seen. Also see

section 2B below.

Plan laboratory hematology presentation for Continuing Education in Hematology (see detailed

instructions in Resident/Fellow Handbook) with a mutually agreed upon time and date at the

Clinical Lab Building (CLB) or at Shadyside (SHY).

2. Specific Activities

General Hematology Laboratory (ATL) The laboratory supervisor, Katie Mulvey, and the hematology lead technologists, Mary Vernetti or Chris Morain will help you with hematology instrumentation and identification of abnormal cases that need to be reviewed. Obtain a password from Ms. Abbie Mallon, to access MediaLab.

A. General

Review procedure manuals in General Hematology, Coagulation and Urinalysis

including the procedures for operating the Iris iQ 200 urinalysis instrument. The

purpose of this review is to learn how a procedure manual is constructed, to

appreciate the CLSI format and to learn how to find a procedure when needed.

The manuals are available in print and online in MediaLab.

Be sure that the Laboratory Hematology Staff Meeting fellow attendance sheet is

completed with your signature at all the staff meetings/laboratory management

meetings that you attend.

Participate in troubleshooting. This includes analysis of problems with function of

instruments, quality control, or patient data that appear spurious. The problems will

be brought to your attention by the technical staff and/or Dr. Contis or designee.

B. Hematologic Microscopy

Review normal PB morphology, understanding variations between adult and pediatric

values. (Review ASCP sets located in room G315, if not previously reviewed or if further

review is needed).

See criteria for evaluating red cells on sheet “Red Cell Morphology Classification

(1+, 2+, 3+)” in the hard copy supplement.

Evaluate all abnormal slides referred to the pathologist (ongoing throughout rotation). This

is performed by checking the designated hself in the Pediatric Bone Marrow sign out room

(G306) to see if there are slides for review (bone marrow technologists will usually bring

them to you). When slides are designated, the trainee should obtain clinical information

about the patient, including checking Copath for prior pathologic evaluations, then review

the slide including performing a 100-200 cell differential for peripheral blood films and a

morphologic review of the cytospin slide for a fluid. The trainee should then formulate a

differential diagnosis and then review the case with the pathologist on the laboratory

service (see schedule). This review is an essential part of the laboratory’s function since

the ATL lab is often the first place where an abnormality is detected.

Peripheral Blood Films

Body Fluid Cytospin slides

Keep a list of peripheral blood/body fluid slides that you reviewed and pertinent information

Correlate body fluid results from cytology laboratory with hematology findings.

Alert Dr. Miroslav Djokic to interesting peripheral blood films or body fluid slides. Provide

her the slides, a photocopy of the lab values and clinical information.

C. Automated Equipment: Coulter DxH800 & LH750, Cellavision

Review information provided in your folder

Review procedure manual

Observe:

Setup/Cleaning of instrument

QC/QA Procedures, graphing

Operation of Coulter and Cellavision

Understand principles of instrument. This is discussed in procedure manual and also lead

techs can answer questions.

Review interpretation of Coulter dot plots and causes of spurious results. Use procedure

manual as well as cases you observe in the laboratory.

See examples on the “Complete Blood Count” in the hard copy supplement.

See 2 slides explaining histograms and dot plots.

See up-to-date, “Automated Hematology Instrumentation”.

Learn to evaluate normal and abnormal patterns.

Understand meaning of individual flags and mechanisms for evaluating flags.

Know what a flag is.

Review CAP checklists & Instrumentation QC/QA data.

Urinalysis

1. Sysmex UF-1000i:

Review information provided in your folder


Observe set-up and urinalysis runs on the analyzer

Observe:

Set up, preparation of reagents, samples


Running, evaluation of samples

Review urine sediment images in Iris iQ200 and know about major urine microscopy

findings and their significance.

Understand principles of instrument and manual back-up procedures (when and how)

Understand sensitivities and specificity of color reactions and drug interference.

Understand principles of instrument and back-up procedures (when and how).

Review Educational Resources

Crystals and casts

RBC, WBC, squamous epithelial cells

Bacteria, yeast

2. Coagulation automated equipment: STA-R Evolution (Diagnostica Stago, Inc)


Observe:

Set up, preparation of reagents, samples


Running, evaluation of samples

Understand significance of results for pre-operative screening and monitoring

anticoagulant therapy by reading text materials or original literature and by discussion

of issues with the pathologist on the laboratory service. This should include

understanding the significance and use of the INR and anti-Xa assay.

Observe the D-dimer procedure and understand its clinical usage as a negative

predictor for DVTs and as a positive indicator of DIC.

Administrative Aspects of Laboratory

Attend the biweekly Hematology Laboratory meeting during your 3-week rotation.

When: Every other Wednesday at 10:30 AM, 6th Floor, CLB (Dr. Contis updates the

meeting schedule and sends out agenda).

Where: 6th Floor, CLB

If the resident’s rotation includes the last week of the month, they can attend the

Shadyside Laboratory Operation meeting at 8:30 AM, at Shadyside Hospital, the last

Tuesday of each month. Contact Dr. Contis for information and location.

3. Special Hematology Laboratory Many tests are sent out to reference laboratories.

A. General Review test menu and procedure manual

Observe any test procedures being performed.

B. Specific Tests:

Hemoglobin Evaluation

Understand co-migration of hemoglobins and methods for distinguishing them, clinical

significance, relationship to Sickledex.

Understand mechanisms of false positives/negatives, effect of transfusion on findings.

Review HPLC Examples for Variant Hemoglobins, shelved in G315 under Hematology

References.

Review Color Atlas of Hemoglobin Disorders: A compendium based on Proficiency Testing

(located in G315).

Understand principles of HPLC for hemoglobin separation.

Review and interpret tracings that come back from the reference laboratories and from

CHP Laboratories.

Review chromogram information for hemoglobinopathy information (in supplemental

materials)

Contact Dr. Steven Dobrowolski at CHP to arrange a time for review of HPLC and follow-

up study results. Residents are expected to meet with Dr. Dobrowolski twice at CHP.

Test of RBC function

Know how these tests are performed and how they are useful:

RBC enzymes (G6PD, PK, GPI, etc.)

Teaching case /recent send out file

Read about

Plasma, serum, urine, hemoglobin


Read about

Osmotic fragility


Read about

Heinz bodies


Read about

Miscellaneous Tests

Acetylcholinesterase (ACHE)

Muramidase

Urine, serum myoglobin

Flow cytometry for PNH (If not reviewed in Flow rotation)

Neutrophil oxidative product formation analysis (If not reviewed in Flow rotation.)

Staining of bone marrow smears

Routine Stains

Cytochemical and immunocytochemical methods/procedures

Other Hematology Testing: (Vitamin B12, serum and RBC folate, serum iron

and ferritin)

These tests are now done in chemistry.

Review how they are used in the workup of hematologic disorders with Dr. Contis.

Review methodology utilized (see Chemistry lead tech).

References:

Color Atlas of Hemoglobin Disorders, A Compendium Based on Proficiency

Testing. James D. Hoyer and Steven H. Kroft, Editors, 2003.

McPherson RA, Pincus MR (Eds.) Henry’s Clinical Diagnosis and Management by

Laboratory Methods, 21st Edition 2007.

Haemoglobinopathy Diagnosis, 2nd edition. Barbara Bain, Blackwell Science, 2006.

I have completed the General Hematology Laboratory Checklist and reviewed it with

Dr. Contis

Resident/Fellow Name (Printed)

Signature ___________________________________ Date ___________________

___________________________________________

Signature of Lydia Contis, MD or designee

Before completing your rotation, please review the completed checklist with Dr. Contis, sign and turn into Dr. Swerdlow’s office.

HEMOGLOBIN ANALYSIS CASE LOG

ACCESSION NUMBER DIAGNOSIS

PB AND FLUID REVIEW LOG


PB AND FLUID REVIEW LOG


Continuing Education in Clinical Chemistry and Hematology Description: The Continuing Education Conference is organized around a case discussion (resident) and scientific issue or laboratory management/quality assurance presentation (faculty). A method or technical issue may also be presented by a lead technologist. Coordination between the 2-3 presenters is encouraged. The sessions are targeted toward technologist education. Discussion between pathologists/trainees and technologists is encouraged. Periodic updating of important basic concepts is welcome. Please seek input from Dr. Contis, or another hematopathologist when planning your hematology presentation. Day, time and location: Determined accourding to ta mutually agreed upon time with technologists and resident. This is facilitated by Dr. Contis. The location is usually CLB Room 1021. Frequency of presentation: Each resident on the laboratory hematology rotation will present once, usually on the last week of their rotation. Length of each presentation: 15-20 minutes Examples of Topics:

1. Case discussion (Resident or fellow).

a. “Atypical lymphocytes,” 9/4/07, Dr. A. Henry

b. “Case of G6PD deficiency,” 9/25/07, Dr. I Batal

c. “Identification of urinary crystals,” 10/16/07, Dr. M. Rollins-Raval

d. “Nucleated Red Blood Cells and the Coulter LH 750 and the Sysmex XE 2100,”

12/16/08, Dr. Hannah Kastenbaum

e. "Scaling the Peaks: High-Performance Liquid Chromatography And the Detection of

Hemoglobin S", 5/5/09, Dr. Milon Amin

f. “Cystine crystals,” 12/12/10, Dr. Kelley Garner

g. “Cryoglobulinemia and Cold Agglutinin Disease: Blood Smear and Other Findings,”

02/09/2016, Dr. Dinesh Pradhan

2. Method or technical issue (Lead technologist or other)

a. “Validation of reference ranges for automated ESR method.” 9/4/07, E. Austin

b. “Review and tips for making thick smears for blood parasites,” P. Nowack

c. “Review of PFA-100,” 9/9/08, Dr. S. Monaghan

d. “Review of Bronchoalveolar Lavage (BAL) Analysis for Cell Counts & Differentials,

12/2/08,” Dr. S. Gibson

e. “A Proposed Plan for the Comparison Evaluation of the Coulter DxH 800, Sysmex

XE, and Coulter LH 750,” Dr. S. Monaghan

3. Scientific issue, quality assurance or management (Faculty)

a. Discuss a method, disease, recent literature, QA study, etc.

b. “Immature reticulocyte fraction,” 10/21/08,” Dr. L. Contis

c. “Automated Cell Counts on Pleural Fluid: Review of a Study on the Sysmex XE-

2100, 12/2/08,” Dr. R. Felgar.

d. “Platelet Counting by the Coulter LH 750 and Sysmex XE 2100,” 12/16/08, Dr. S.

Monaghan

Pediatric Hematopathology Checklist

Note: Items indicated in BOLD constitute the basic knowledge expected of residents rotating in Hematopathology. Additional (non-bolded) items should also be included for advanced learners including fellows.

Orientation with Hematopathologist on Pediatric Hematopathology service.

Knows how normal pediatric blood and bone marrow differ from those of adults.

Knows special aspects of neonatal hematopathology (see K. Foucar, “Neonatal

Hematopathology: Special Considerations” in Collins RD and Swerdlow SH, eds. Pediatric

Hematopathology and Maria Proytcheva Diagnostic pediatric hematopathology).

Knows role of cytogenetic and molecular diagnostic studies in evaluating hematopoietic /

lymphoid disorders in bone marrow and blood.

Learn diagnostic criteria using multiparameter approach and clinical implications for each of

the following:

Diagnosis / Finding Observed

Actual Case

Observed Teaching File Case

Read About

NEOPLASTIC DISORDERS

Acute Lymphoblastic Leukemia

B-lymphoblastic leukemia / lymphoma

B-lymphoblastic leukemia/lymphoma with recurrent cytogenetic abnormalities (See WHO book for specific categories)

T- lymphoblastic leukemia / lymphoma

Acute Myeloid Leukemias

Acute Myeloid Leukemia with 11q23 abnormality

Acute Myeloid Leukemia with recurrent cytogenetic abnormality, other

Acute Megakaryoblastic Leukemia

AML/MDS associated with congenital marrow failure syndromes

Acute Myeloid Leukemia, not otherwise specified

Mixed lineage acute leukemia

Myeloid proliferations associated with Down Syndrome

Acute Myeloid Leukemia

Transient Abnormal Myelopoiesis

Chronic Myeloproliferative Neoplasms

Chronic Myelogenous Leukemia

Myelodysplastic/Myeloproliferative Disease

Juvenile Myelomonocytic Leukemia

Myelodysplastic Syndromes

Childhood Myelodysplastic Syndromes Refractory cytopenia of childhood

Mature Lymphoid Neoplasms

Burkitt Lymphoma

Diffuse Large B-cell Lymphoma

Anaplastic Large Cell Lymphoma, ALK+

Pediatric Nodal Marginal Zone Lymphoma

Pediatric Follicular Lymphoma

Systemic EBV+ T-cell LPD of Childhood

Hydroa Vacciniforme-like Lymphoma

Nodular Lymphocyte Predominant Hodgkin Lymphoma

Classical Hodgkin Lymphoma

Histiocytic Neoplasms

Langerhans cell histiocytosis

Mast Cell Disease

Metastatic Tumors

Neuroblastoma

Rhabdomyosarcoma

Ewing sarcoma

NON-NEOPLASTIC DISORDERS

Congenital Disorders/Syndromes with Prominent Hematologic Abnormalities (Hereditary bone marrow failure)

Fanconi Anemia

Diamond Blackfan Syndrome

Congenital Dyserythropoietic Anemia

Congenital Sideroblastic Anemia

Pearson Syndrome

Severe Congenital Neutropenia/Kostmann’s Syndrome

Cyclic Neutropenia

Shwachman-Diamond Syndrome

Dyskeratosis Congenita

Reticular Dysgenesis

May-Hegglin Anomaly

Bernard-Soulier Syndrome

Wiskott-Aldrich Syndrome

Congenital Amegakaryocytic Thrombocytopenia

Familial Platelet Syndrome with Predisposition to Acute Myeloid Leukemia

X-linked thrombocytopenia

Thrombocytopenia with Absent Radii (TAR)

Gray Platelet Syndrome

X-Linked Lymphoproliferative Disorder

DiGeorge Syndrome

Severe Combined Immunodeficiency Disease

Red Cell cytoskeletal/membrane abnormalities-hemolytic anemia

Red Cell enzyme deficiencies-hemolytic anemia

Hemoglobinopathies

Sickle cell disease

Thalassemia

Other

Gaucher Disease

Niemann-Pick

Mucopolysaccharidoses

Other Anemias and Conditions

Transient erythroblastopenia of childhood

Alloimmune hemolytic anemia of newborn

Iron deficiency

B12/folate deficiency

Parvovirus

Thrombocytopenia (see also above)

Autoimmune Thrombocytopenic Purpura

TTP/Hemolytic Uremic Syndrome

Congenital syndromes

Drugs/toxins

Infection-associated

Thrombocytosis

Neutropenia

Immune neutropenia

Neutrophilia/Leukemoid Reaction

Infection/inflammatory disorders

Medications

Eosinophilia

Basophilia

Lymphopenia

Infection

Medication

Autoimmune

Nutritional Deficiency

Congenital Disorders

Lymphocytosis

Epstein Barr Virus (infectious mononucleosis)

Pertussis

Infection, other

Granulomas

Myelofibrosis

Aplastic Anemia

Idiopathic Drugs

Secondary

Infection Associated

Drugs/toxins

Hemophagocytic/Lymphohistocytic Syndromes

Familial lymphohistiocytosis

Secondary hemophagocytic/macrophage activation syndrome

Immunodeficiencies

Autoimmune Lymphoproliferative Syndrome

Other Primary Immunodeficiencies (see above)

PRESENTED THE FOLLOWING PEDIATRIC BONE MARROW OR LYMPH NODE CASES (Fellows should submit presentation in portfolio)

PHB NUMBER DIAGNOSIS

UTILIZED THE FOLLOWING BONE MARROW RESOURCES

Swerdlow SH, Collins RD Pediatric Hematopathology, Churchill Livingstone, 2001.

Orkin, SH, et al., Nathan and Oski’s Hematology of Infancy and Childhood, 7th Edition.

Penchansky L, Pediatric Bone Marrow, Springer, 2004.

Proytcheva, Maria A. Diagnostic pediatric hematopathology. Cambridge: Cambridge University Press; 2011.

NOTE: Reading is an important component of this rotation. It is recognized that not all of the above resources can be used nor can most be read in entirety. Use of electronic and other resources to find and read up-to-date journal articles is also critical. I have completed the Pediatric Hematopathology Checklist Name __________________________________________ (printed) __________________________________________ (signature) Date __________________________________________

UPMC PRESBYTERIAN SHADYSIDE

Automated Testing Laboratory

Pathologist Review Form

Patient Name /Medical Record #

Hospital: PUH/CLB SHY CHP MWH Date:

Patient Diagnosis:

Specimen Type: Peripheral blood smear Pleural fluid Peritoneal fluid CSF Other

Tech Name/ Tech comments:

PATHOLOGIST COMMENTS:

BLID=Blasts are identified RMCP=Reactive mesothelial cells present

FCSR=Flow cytometry studies recommended GTCBM=Correlation with pending bone marrow evaluation recommended

AUERP=Auer rods present INCP=Inflammatory cells present

CBCLDF=Atypical lymphoid population, worrisome for lymphoproliferative disorder. Recommend flow cytometric evaluation if clinically

indicated

GTAMC=Clusters of atypical mononuclear cells, worrisome for malignancy, correlation with

cytology recommended

GTPLC=Plasma cells identified, correlation with flow cytometry studies recommended

BACIE= Intracellular and extracellular bacteria present

Additional Pathologist comments:

Correct the Differential? Yes / No Stain quality: Satisfactory / Unsatisfactory

Pathologist comment to tech:

RESIDENT/FELLOW :

PATHOLOGIST :

Children’s Hospital of Pittsburgh of UPMC

AUTOMATED TESTING LABORATORY 412-692-9836

PATHOLOGIST REVIEW

HEMATOPATHOLOGY DEPARTMENT

Name/Medical Record #:

Date/Accession #:

Patient Diagnosis

Peripheral Blood Smear: Yes / NO

Fluid type: CSF, Synovial, Pleural, Peritoneal, Pericardial, Bronchial Lavage

TECHNOLOGIST COMMENT:

TECH SUBMITTING REVIEW:

PATHOLOGIST COMMENT: To be entered into Sunquest

SEE CORRECTED DIFF

PATHOLOGIST COMMENT: For Technologist only

REVIEW RESIDENT/FELLOW:

REVIEW PATHOLOGIST:

Clinical Experience in Hematology

Clinical Experience in Hematology at UPMC Shadyside

Clinical Hematology / Performance of Bone Marrow Experience

All activities are based at Hillman Cancer Center, 2nd

Floor unless indicated otherwise. Upon arrival, contact the on site bone marrow technologist who can help orient you to the facility and facilitate your opportunity to learn how to perform bone marrow examinations. The bone marrow technologist can either be found in room A220.36 or paged at (412) 958-8812 or the in-house pager 11443. This can also be facilitated by your seeing Celina Fortunato, in G325 or one of the bone marrow technologists who can call over to UPMC-Shadyside the week before you go over there.

MONDAY

TUESDAY

WEDNESDAY

FRIDAY

AM Dr. Redner Clinic (Hillman Cancer Center, 2

nd Floor

Conference Rm. One).

YOU ARE RESPONSIBLE FOR CONTACTING DR. REDNER ONE WEEK PRIOR TO YOUR VISIT TO HIS CLINIC VIA EMAIL TO CONFIRM HE HAS CLINIC

Learn to perform bone marrow aspirates /biopsies with Physician’s Assistant

Go with Bone Marrow Technologist on all marrows if Physician’s Assistant is not available

Dr. R. Smith Clinic, Area A, Pod 1

Dr. Kiss/Dr.

Bontempo’s Hematology Clinic, Area A, Pod 3, Rooms 3B,C,D (every other Friday)

PM After Dr. Redner’s clinic is done, go with Bone Marrow Technologists on all marrows.

Dr. Lim/Dr. Agha’s Clinic, 4

th Floor,

Hillman Cancer Center,

Learn to perform bone marrow aspirates /biopsies with Physician’s Assistant

Begin UPMC-Presbyterian based flow cytometry laboratory rotation.

Report to: Clinical Laboratory Building 9

th Floor, Room 9033

3477 Euler Way Pittsburgh, PA 15213 412-864-6180

Objectives:

Learn how clinical hematology is practiced including patient concerns and what clinicians need from pathologists.

Know how to perform bone marrow biopsies and aspirates including actually performing preferably at least 2 procedures.

Know how bone marrow specimens are processed.

Performance of Bone Marrow Aspirations & Biopsies

Performance of bone marrow aspirations and biopsies (with hematology/oncology

division) Trainees are expected to learn how to perform bone marrow aspirations and biopsies. They

should aim to observe and then perform a total of about ten marrows. It is recognized that this goal may not be met. Some of this must be done while the trainee is on their UPMC-P/Hillman Cancer Center Hematology rotation. The remainder should be done later in their training (See below).

A. The trainee will be able to observe and perform marrows as part of the clinical

experience in hematology (see “Clinical Experience in Hematology”).

B. The trainee is required to keep a record of each marrow observed and performed

including the name of the patient, bone marrow number and diagnosis. For the bone

marrows actually preformed, the person supervising the procedure needs to

sign off on the form. In addition, the aspirate smear and biopsy obtained must

be reviewed by a faculty member to assess and document their adequacy. The

form should be completed at the end of the rotation and given to Dr. Swerdlow’s

coordinator in room PUH G333. There is also a hard copy of this form in the red

packet.

C. The trainee should also try to observe several pediatric marrows during the

pediatric/laboratory hematology section of the rotation. These should also be

recorded on the log when noting which are pediatric cases or use a separate sheet

and check off pediatric at the top.

Residents have the opportunity to perform bone marrow aspirates and biopsies at the VA hospital later in their training.

HEMATOPATHOLOGY ROTATION PERFORMANCE OF MARROW BIOPSIES AND ASPIRATES FORM

Satisfactory completion of the rotation REQUIRES the return of this form.

Name: Rotation Dates: AGE OF PATIENTS: ADULT PEDIATRIC

BIOPSIES / ASPIRATES PERFORMED

TO BE COMPLETED BY RESIDENT/FELLOW TO BE COMPLETED BY CLINICAL SUPERVISOR TO BE COMPLETED BY HEMATOPATHOLOGIST

Patient Name (REQUIRED)

PHB Number (REQUIRED)

Aspirate Biopsy Signature Satisfactory Problem INITIALS Aspirate Biopsy

S U NA S U NA

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

(Please use back of form if needed.) S = SATISFACTORY U = UNSATISFACTORY (PUT COMMENT) NA = NOT

APPLICABLE

BIOPSIES / ASPIRATES OBSERVED

Patient Name (REQUIRED)


Aspirate Biopsy Patient Name (REQUIRED)


Aspirate Biopsy

1. 7.

2. 8.

3. 9.

4. 10.

5. 11.

6. 12.

Please get recut H& E and aspirate smear stained. Have attending hematopathologist review and evaluate in section above.

TRAINEE SIGNATURE DATE DIRECTOR (OR DESIGNATE) SIGNATURE DATE

PLEASE RETURN COMPLETED FORM PRIOR TO END OF ROTATION TO DR. SWERDLOW’S COODINATOR, RM G333.

Flow Cytometry Laboratory

Experience

Flow Cytometry Laboratory Experience Introduction to flow cytometry

Understanding of flow cytometric immunophenotypic techniques and interpretation of the resultant data is an integral part of all the bone marrow and lymph node rotations. In addition, however there is a brief concentrated exposure to the flow cytometry laboratory including the technical aspects of flow cytometry and the basic operation of a flow cytometry laboratory. In most cases this will occur following the core pediatric bone marrow rotation (week 4). This is also the opportunity to learn about flow cytometric DNA content study.

1. Meet with the Flow Cytometry Lab lead technologist or designate for orientation.

2. Become familiar with instrumentation and procedures in laboratory under the guidance

of the lead technologist.

Immunostaining.

Acquisition and analysis using flow cytometry.

Quality control/quality assurance.

Operation of a large clinical flow cytometry laboratory

3. Complete checklist.

4. Educational materials available:

Flow Cytometry First Principles. Alice L. Givan.

Flow Cytometry in Clinical Diagnosis. 4rd edition, editors: D. Keren, J.P.

McCoy and J.L. Carey.

Flow cytometric immunophenotyping for hematologic neoplasms. Blood

111(8)3941-3967, 2008.

Flow Cytometry Rotation Checklist


Orientation with the Lead Technologist or her designate.

Understand the principles of flow cytometric immunophenotyping.

Gain familiarity with instrument set –up, compensation and quality control.

Gain familiarity with procedures for surface and cytoplasmic antibody staining.

Understand the principles of analysis.

Perform additional data analysis using DIVA software on specimens previously analyzed in the clinical Flow Cytometry Laboratory

Know the immunophenotypic characteristics of the following entities:

Observed

Observed

Read

Diagnosis/Finding Actual Case

Teaching File Case

About

Normal bone marrow

Hematogones

Reactive Lymph Node

Lymphoma

Follicular lymphoma

Chronic lymphocytic leukemia/Small lymphocytic

lymphoma

Mantle Cell lymphoma

MALT lymphoma

Diagnosis/Finding

Observed Actual Case


Read About

Burkitt lymphoma

T-cell lymphoma

Chronic leukemia

Hairy Cell Leukemia

B-Cell Prolymphocytic Leukemia

T-Cell Prolymphocytic Leukemia

Sézary Syndrome

T-cell and NK cell Large Granular Lymphoproliferative Disorders

Adult T-cell Leukemia / Lymphoma

Acute Myeloid Leukemia

Acute Promyelocytic Leukemia with t(15;17) (q22;q12)

PML-RARA

Acute Myeloid Leukemia associated with t(8;21)

Acute Myeloid Leukemia associated with inv(16)

Acute Myeloid Leukemia with monocytic differentiation

Acute Megakaryocytic Leukemia

Acute Lymphoblastic Leukemia

B-Lymphoblastic leukemia/lymphoma

T-lymphoblastic leukemia/lymphoma

Minimal Residual disease in Acute Lymphoblastic Leukemia

Paroxysmal Nocturnal Hemoglobinuria

Chronic Granulomatous Disease

Neutrophil Oxidative Burst Analysis

DiGeorge syndrome evaluation

Leukocyte adhesion molecule deficiency

UTILIZED THE FOLLOWING FLOW CYTOMETRY RESOURCES

McPherson, R.A., Pincus, MR., Henry’s Clinical Diagnosis and Management by Laboratory Methods 21st edition, 2007. Chapter 33- The Flow Cytometric Evaluation of Hematopoietic Neoplasia, Wood and Borowitz, pg 599.

Givan, A.L., Flow Cytometry, First Principles, 2nd Edition, 2001.

Keren, D.F., McCoy, J.P., and Carey, J.L., Flow Cytometry in Clinical Diagnosis, 3rd

Edition, 2001.

Craig, F.E., Foon, K.A., “Flow cytometric immunophenotyping for hematologic

neoplasms.” Blood 111. 8 (2008): 3941-3967.

I have completed the Flow Cytometry Checklist Name (printed)

(signature)

Date

Test Menu of Routine Flow Cytometry Panels

Acute: CD16&57/CD7/CD4/CD3/CD56/CD8/CD2/CD45

CD36/CD123/CD64/CD33/CD34/CD14/HLA-DR/CD45

CD15/CD56/CD117/CD13/CD11b/CD16/HLA-DR/CD45

CD7/CD13&33/CD19/CD56

Kappa/Lambda/CD5/CD19/CD10/CD38/CD20/CD45

cytoplasmic TdT/MPO/CD3/CD34 **Pediatric specimens also include the CD58/CD123/CD34/CD19/CD10/CD38/CD20/CD45

Basic Screen: Limited evaluation of lymphoid and myeloid cells to be used when the following criteria are met: no

significant history, no cytopenias, and no morphologic abnormality e.g. staging for Hodgkin lymphoma. Also, to

follow-up documented CML, or rule-out a myeloproliferative disorder such as CML, polycythemia vera (PV),

essential thrombocythemia (ET), or idiopathic myelofibrosis.

CD14/CD13&33/CD45/CD34


CLL PB/BM: CD14/CD13&33/CD45/CD34

CD16&57/CD7/CD4/CD3/CD56/CD8/CD2/CD45

CD23/CD49d/CD5/CD19/CD38//FMC7/CD200


CLL LN: CD16&57/CD7/CD4/CD5/CD56/CD3/CD2/CD8

CD23/CD49d/CD5/CD19/CD38/-/FMC7/CD200


Mini CLL Follow-Up (PB or BM): Limited evaluation of chronic lymphocytic leukemia (CLL) or small

lymphocytic leukemia (SLL) with previous diagnosis at UPMC including flow cytometric evaluation. PB or BM

submitted for evaluation of CLL, and morphology review is consistent with that diagnosis and does NOT

demonstrate another disease process e.g. increased blasts.

CD14/CD13&33/CD45/CD34

CD23/CD49d/CD5/CD19/CD38/-/FMC7/CD200


DiGeorge: CD45RA/CD62L/CD3/CD4

Lymph PB/BM: CD14/CD13&33/CD45/CD34



Lymph LN: CD16&57/CD7/CD4/CD5/CD56/CD3/CD2/CD8 Kappa/Lambda/CD5/CD19/CD10/CD14/CD20/CD45

**Pediatric specimens also include the cytoplasmic TdT/MPO/CD3/CD34

MDS: CD16&57/CD7/CD4/CD3/CD56/CD8/CD2/CD45



CD7/CD13&33/CD19/CD56


Mini AML: Previous diagnosis of acute myeloid leukemia (AML) established at UPMC including flow

cytometric evaluation (NOT flow only). PB or BM submitted for evaluation. Review previous

phenotype and add additional aberrant markers when appropriate.




Mini B-ALL: Previous diagnosis of B-lineage acute lymphoblastic leukemia (ALL) established at

UPMC including flow cytometric evaluation (NOT flow only). PB or BM submitted for evaluation of

ALL. Review previous phenotype, and add additional aberrant markers when appropriate.

CD14/CD13&33/CD45/CD34


CD58/CD123/CD34/CD19/CD10/CD38/CD20/CD45 (30,000 events)

cytoplasmic TdT/MPO/CD3/CD34 **If MRD evaluation is also requested at the same time, the CD58 tube will be

done in a separate flow procedure (FC2).

B-ALL MRD: CD58/CD123/CD34/CD19/CD10/CD38/CD20/CD45 (maximum # of events collected)

Mini B-cell Lymphoma Follow-up (PB or BM): Limited evaluation for follow-up B-cell lymphoma

with previous diagnosis at UPMC including flow cytometric evaluation (NOT flow only). PB or BM

submitted for evaluation of lymphoma, and morphology review consistent with that diagnosis and does

NOT demonstrate another disease process e.g. increased blasts.

CD14/CD13&33/CD45/CD34

Kappa/Lambda/CD5/CD19/CD10/CD38/CD20/CD45 **bcl-2 testing should be performed on all cases with a history of follicular lymphoma. or

if the requisition asks for testing for bcl-2, bcl-2 gene rearrangement, or t(14:18) testing

(even fi this is indicated in the molecular or cytogenetic area of the requisition.

Mini T-ALL: Previous diagnosis of T-lineage acute lymphoblastic leukemia (ALL) established at

UPMC including flow cytometric evaluation (NOT flow only). PB or BM submitted for evaluation of

ALL. Review previous phenotype, and add additional aberrant markers when appropriate.

CD14/CD13&33/CD45/CD34


CD7/CD13&33/CD5/CD56

Kappa/Lambda/CD5/CD19/CD10/CD38/CD20/

CD45 cytoplasmic TdT/MPO/CD3/CD34

Myeloma: CD14/CD13&33/CD45/CD34 CD16&57/CD7/CD4/CD3/CD56/CD8/CD2/CD45

CD3/CD138/CD19/CD56


cytoplasmic Lambda/CD138/CD19/Kappa

NOBA: Blank

Resting (DHR only)

Stimulated 10

Stimulated 15

Stimulated 25

**Both a patient and a control are stained for this assay.

PNH: RBCs: CD235a/CD59

WBCs: Flaer/CD16/CD33/CD15/CD14/-/CD45

**Both a patient and a control are stained for this assay.

8-Color CSF

Tube: Kappa/Lambda/CD5/CD13&33/CD34/CD14/CD19/CD45

8-Color B-cell

Tube: Kappa/Lambda/CD5/CD19/CD10/CD14 or CD38/CD20/CD45

The following page includes all of the validated extra tubes that can be ordered in the Flow Cytometry

Laboratory.

VALIDATED EXTRA TUBES

FITC PE PerCP ‐Cy5.5

PE‐ Cy7

APC APC‐ H7

V450 V500 Short name

CD2 CD7 CD117 CD25 Mast Cell

CD2 CD8 CD3 CD4

CD2 CD30 CD3 CD19 CD30

CD7 CD26 CD3 CD4 SEZ

CD7 CD1a CD3 CD5 CD45

CD16&57 CD7 CD3 CD56

CD16&57 CD7 CD4 CD3 CD56 CD8 CD5 CD45 PB/BM T W/5

CD16&57 NKG2A CD94 CD3 CD8 CD56 CD45 KIR (2 OF 2)

CD23 CD49d CD5 CD19 CD38 FMC‐7 CD200 49d

CD52* CAMPATH

CD61 CD13&33 CD41a CD34 MEGAKARYOCYTE

CD103 CD11c CD20 CD25

CD123 LAIR 11c CD25 CD103 CD3 CD20 CD45 HAIRY

CD158a CD158e CD16 CD3 CD158b1 CD8 CD56 CD45 KIR (1 OF 2)

Bcl‐2 CD10 CD20

Bcl‐2 CD10 CD19

BLK Kappa BLK Lambda CD19 CD5

BLK Kappa BLK Lambda CD20 CD10

FMC‐7 CD23 CD19 CD5 FMC7

Lambda Kappa CD19 CD5

Lambda Kappa CD20 CD10

TCR a/b TCR g/d CD3 CD25

TCR a/b TCR g/d CD3 CD4 CD8 CD45 ALPS

TdT CD22 CD79a CD34 CD45 CYTO B‐CELL

*CD52 FITC for consideration for CAMPATH therapy put in combination with previously tested

antibodies

ANTIBODIES AVAILABLE IN THE FLOW CYTOMETRY LABORATORY

ANTIBODY FITC PE PerCP PerCP‐ Cy5.5

PE‐Cy7 APC APC‐H7 Alexa Fluor

750 V450 V500

CD1a X

CD2 X X

CD3 X X X X X X

CD4 X X X CD5 X X X X X

CD7 X X

CD8 X X X X X X (C) CD10 X X X

CD11b X

CD11c X X

CD13 X X

CD14 X X X CD15 X X

CD16 X X X X

CD19 X X X

CD20 X X X X X

CD22 X X

CD23 X X

CD24 X

CD25 X X

CD26 X

CD30 X

CD33 X X X

CD34 X X

CD36 X

CD38 X X

CD41a X

CD43 X X

CD45 X X X CD45RA X

CD45RO X

CD49d X

CD52 X

CD56 X X X

CD57 X

CD58 X

CD59 X

CD61 X

CD62L X

CD64 X

CD79a X

CD79b X X

CD81 X

CD94 X

CD103 X X

CD117 X

CD123 X X

CD138 X

CD158a X

CD158b1 X

CD158e X

CD200 X

BCL‐2 X

Flaer X

FMC‐7 X X

GLYCO A (CD235a)

X

HLA‐DR X

Kappa X X X

Lambda X X

LAIR X X

MPO X

NKG2A X

TCR a/b X

TCR g/d X

TdT X

Guidelines for Flow Cytometry Staining Decisions

1. Pathologists Decisions. The pathologist who is assigned to the appropriate service

should be called for a decision in any of the following circumstances:

a. Limited specimen. Either there are too few cells to set-up the indicated panel or the

appropriate panel would use the specimen in its entirety. For some limited CSF

specimens, technologists can make a decision if there is a previous history, with flow

cytometry run in our system, of CD10 positive precursor-B acute lymphoblastic

leukemia, CD34 positive acute myeloid leukemia, or B-cell lymphoma The

Pathologist should be called for limited CSF samples if there is history of another

malignancy. Also, if there is no history of a hematolymphoid malignancy, such as

leukemia, lymphoma, or myeloma, after review of clinical information, the 8-color

CSF tube can be run.

b. There are questions about any of the information available (including the history,

clinical information, test requested or morphologic appearance).

c. For whatever reason, there is uncertainty regarding the appropriate panel.

d. A technologist who has met the required morphology or decision competency level is

not available.

The following protocol is recommended when calling a pathologist for a decision:

a. Identify yourself and inform the pathologist that you are calling for a flow decision.

b. Notify the pathologist of the following information:

i. Cellularity / adequacy of specimen. Alert the pathologist if the cellularity is low.

Tell them the total number of cells and / or approximately how many tubes can be set-up.

ii. Specimen Type (peripheral blood, bone marrow, fluid etc.).

iii. Flow-only or In-house.

iv. Test requested (evaluation of lymphocytes or blasts).

v. Clinical Information provided.

vi. Previous pertinent diagnoses in CoPath including the phenotype.

vii. Presence and quantity of abnormal cells including blasts / immature mononuclear cells, lymphocytes / abnormal lymphocytes, plasma cells, and unidentifiable cells.

2. Technologist Decisions. Flow decisions can be made by a technologist who has met

the required morphology and decision competency level, in the following circumstances:

a. New Adult Acute Leukemia. A complete “Acute Leukemia Panel” can be set-up if the

smear demonstrates numerous blasts, immature cells, or monocytes. The designated

hematopathologist should be paged with a text message to alert them about a possible

new case of acute leukemia. The pathologist should be called directly if there are any

questions about the tubes that should be set-up, the urgency of the results, or the

morphologic appearance. The pathologist should also receive a text message when the

case is completed in order to review the pdfs.

b. Full panel. One of the standard complete panels can be set-up if the requisition

indicates the disease entity being evaluated, and both the previous history in CoPath,

and the morphologic review are consistent with that diagnosis. Technologists are

encouraged to be proactive in ordering any additional tubes indicated by previous flow

cytometric results or the information provided on the requisition e.g. the bcl-2 extra in

the evaluation of BM involvement by follicular lymphoma. Novel, untested,

combinations are NOT recommended unless the antibodies have already been

evaluated in their standard combinations.

c. Limited panel. One of the authorized limited panels (see the test menu list) can be

ordered if the following criteria are met:

i. The patient is being evaluated for a disease entity for which there is a

previous diagnosis at UPMC-Presbyterian/Shadyside including flow cytometric evaluation (NOT flow only, except for PB evaluation of CLL).

ii. The requisition indicates follow-up of that disease entity.

iii. The morphologic findings are consistent with that diagnosis, or treatment of that entity, and do NOT indicate another disease process.

d. CSF specimens. If there are only enough cells available for one tube, flow

cytometry technologists can make a decision of which tube to run, based on

the following guidelines:

i. Previous history of precursor-B acute lymphoblastic leukemia with flow cytometry

run in our system:

• CD10 positive - set up CD10 / CD13&CD33 / CD19 / CD34

• CD10 negative - call for decision

• Any questions - call for decision

ii. Previous history of acute myeloid leukemia with flow cytometry run in our system:

• CD34 positive - Set up 8-color CSF tube • CD34 negative - call for decision • Any questions - call for decision

iii. Previous history of B-cell lymphoma with flow cytometry or previous diagnostic

evaluation in our system:

i. set up 8-color B-cell tube

iv. No history of a hematolymphoid malignancy, such as leukemia, lymphoma,

myeloma, after review of CoPath and available clinical information:

i. set up 8-color CSF tube (K/L/CD5/CD13&33/CD34/CD14/CD19/CD45).

3. Technologist Ordering of Extra's. After review of the results from the original panel,

technologists are encouraged to be proactive in ordering any additional tubes indicated, or

text paging the Pathologists to alert them of the possible need for Extra's. For example:

a. bcl-2 extra: abnormal CD10 positive B-cell population

b. CD23/CD49d/CD5/CD19/CD38/-/FMC7/CD200: abnormal CD5 positive B-cell population.

c. CD123/LAIR/CD11c/CD25/CD103/CD3/CD20/CD45: abnormal CD10 negative,

CD negative B-cell population.

TEST SPECIFICATIONS: CLINICAL FLOW CYTOMETRY LABORATORY Leukemia Panels, CLL/Lymphoma Panels, T-Lymphocyte Subset Panels, PNH, NOBA

DELIVER ALL SAMPLES DIRECTLY TO THE FLOW CYTOMETRY LABORATORY

Clinical Laboratory Building

Room 9032 (9th

floor) 3477 Euler Way

Pittsburgh, PA 15213 (412) 864-6173

FLOW CYTOMETRY LAB HOURS OF OPERATION

Monday through Friday: 8:00 am to 6:00 pm. In all cases, notify the lab before the specimen is sent (412- 864-6173). It is recommended that on Friday specimens be received by 5 pm.

Saturday: Emergency specimens can be processed on Saturday. The laboratory must be notified by 12 pm and the specimen must arrive by 1 pm. The hematopathologist on call can be reached through the UPMC Oakland operator at (412) 647-2345.

Sundays and Holidays: The lab is closed on Sunday and the following holidays: New Year’s Day, Martin Luther King Day, Memorial Day, July 4, Labor Day, Thanksgiving Day and Christmas Day. Specimens should be received by 3 pm on the day before a holiday.

SPECIAL INSTRUCTIONS

Send a completed requisition. In addition FAX the requisition to 412-682-1784 in advance of

sending the specimen.

See specific instructions for storage/transport of specimens.

Use adequate safety measures in transporting specimens.

LEUKEMIA, CLL/LYMPHOMA PANELS

Test Description These tests utilize a panel of monoclonal antibodies in the immunophenotypic analysis of hematopoietic and lymphoid proliferation. The panels are used to assess cell lineage and to look for features that support a neoplastic rather than reactive proliferation.

Specimen Requirements

Bone marrow aspirate: Minimum of 2 ml in a heparinized (green top) tube. Store/transport specimen at room temperature. If possible send one non-heparinized, unstained aspirate smear.

Peripheral blood: One EDTA (preferred; purple top) tube or heparinized (green top) tube

with at least 5 ml of blood. Store/transport specimen at room temperature.

Lymph nodes: Preferably 1 cm3

fresh tissue in RPMI or any other growth media. Normal saline may be used if RPMI is unavailable and transport time is kept to a minimum. A small portion of all tissues (or other tissues) will be processed for histologic sections. Send tissue as soon as possible – preferably to be received within 24 hours. Store specimen at

2-8o

C if delay in transport.

Body fluids: Preferably should be a minimum of approximately 100,000 cells (e.g. 100 cells/ul x 1 ml; 10 cells/ul x 10 ml). Testing can be attempted even on very low count specimens. Send specimen as soon as possible. Store at 2-8

o C if delay in transport.

Fine needle aspirates: Place cores (preferably two) and any additional aspirate in RPMI or other growth media. Normal saline may be used if RPMI is unavailable and transport time is kept to a minimum. Send tissue as soon as possible –

preferably to be received within 24 hours. Store specimen at 2-8o

C if delay in transport.

T-LYMPHOCYTE SUBSET EVALUATION

Test Description This test may be identified as T Cell Subsets, T and B Cells, CD4:CD8 counts and other synonyms. The test panel includes a Total T or Pan T antibody, a Total B cell or Pan B antibody, a Total Helper antibody, a Total Suppressor antibody, the Helper/Suppressor, and a Total Natural Killer antibody. There are no functional tests associated with these antibodies.

A limited CD4 evaluation can be performed if requested.

Specimen Requirements One 4 ml EDTA (purple top) tube or two BD microtainer (purple top) pediatric tubes. Store/transport specimen at room temperature. Testing must performed within 48 hours of specimen collection.

EVALUATION FOR PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH)

Test Description The flow cytometric test for PNH evaluates the GPI-linked markers: CD59 on RBCs; CD24 and CD16 on Neutrophils and CD14 on Monocytes. The WBC assay also determines binding of the fluorochrome labeled toxin Aerolysin.

Specimen Requirements One 4 ml EDTA (purple top) tube. Store/transport specimen at room temperature. Testing must be performed within 48 hours of specimen collection.

EVALUATION FOR NEUTROPHIL OXIDATIVE BURST ASSAY (NOBA)

Test Description This test is a replacement for the Nitro Blue Tetrazolium (NBT) test for Chronic Granulomatous Disease (CGD). The neutrophil oxidative burst assay measures the respiratory burst of neutrophils following stimulation with phorbol 12-myristate 13-acetate (PMA). Patients with CGD lack the usual oxidative burst.

Specimen Requirements One 4 ml EDTA (purple top) tube kept at room temperature. Store/transport specimen at room temperature. Testing must be performed within 24 hours of specimen collection. In addition a normal control (from an UNRELATED donor) MUST accompany the specimen.

CONTACTS, DIVISION OF HEMATOPATHOLOGY

Steven H. Swerdlow, M.D. Director, Division of Hematopathology (412) 647-5191

Wendy Shallenberger

Supervisor, Flow Cytometry Lab (412) 647-6518

Ruth Bates Lead Technologist, Flow Cytometry (412) 864-6180

Rev 8/14

ICD9 Codes for Flow

A list of ICD9 Codes commonly received in the Flow Laboratory. This list is to be used as an aid in interpreting ICD9 codes. It is not to be used to assign ICD9 codes to a case.

IDC9 Disease

78.9 (V78.9) Blood Screen (NOS)

79.99 Viral Infection NOS

172.6 Malignant Melanoma

194.9 Malignant Endocrine Neoplasm (NOS)

201.9 Hodgkin’s Disease (NOS)

202.1 Mycosis Fungoides Unspec Site

202.4 Hairy Cell Leukemia Unspec Site

202.6 Mastocytosis

202.8 Lymphoma Unspec Site

203 Multiple Myeloma No Remission

203.01 Multiple Myeloma In Remission

204.1 CLL - No remission

205 Myeloid leukemia

205.1 CML - No remission

205.11 CML - In remission

207.8 Mast cell leukemia

208.9 Unspecified Leukemia

238.4 Polycythemia Vera

238.7 Lymphoproliferative Chronic (NOS)

238.7 Myeloproliferative Chronic (NOS)

273.3 Macroglobulinemia

284.8 Aplastic Anemia NEC

284.9 Aplastic Anemia NOS

285.6 Lymphadenopathy

285.9 Anemia (NOS)

287.4 Secondary Thrombocytopenia

288 Agranulocytosis

288.1 Function Disorder Neutrophils

288.8 White Blood Disease NEC

289.89 Myelofibrosis

709.9 Skin Disorder NOS

786.5 Chest Pain

789.2 Splenomegaly

Adult Bone Marrow Experience

Adult Bone Marrow Experience (~4 weeks) 1. Adult Bone Marrow Sign Out

A. Sessions with Adult Bone Marrow Technologists -- if not already done during pediatric marrow rotation (eg AP only residents), please set up a time to review peripheral blood and bone marrow aspirate smears with technologists during your first week.(typically Tuesday afternoon is best)

B. Participation in sign-out with staff. Inform Hematopathologist on BM #1 Service that

you are starting the rotation and review expectations in terms of bone marrow preview, sign-out, dictation, and proofing ( see “Trainee Responsibilities during Bone Marrow Rotation”).The trainee should discuss with the faculty the optimal number of cases to evaluate prior to sign-out. .The number of cases the resident is expected to evaluate will increase progressively during the rotation.

C. Review results of ancillary procedures performed on marrows you have reviewed and read addenda that faculty issue (see Special Procedure Review by Resident/Fellow in CoPath).

D. Review of educational materials.

Blood Cell Morphology. (Published by the ASCP). If not already done during pediatric marrow rotation (ie AP only residents).. review the RBC, WBC, Normal and Abnormals Binders with CDs in Hematopathology library (G323) or images and PDF key are also on shared resident drive, under “CP Lecture Material\Hemepath\ASCP Hematology Images”

A teaching set of peripheral blood and body fluid smears is available for check-out from the medical secretary (G306)

A set of cytochemical stains and pb/bm smears is available from the bone marrow technologists. Individual faculty members also have teaching slides.

Foucar, K. Bone Marrow Pathology, 2nd Edition, ASCP Press, 2001.

Foucar, K, Viswanatha DS, Wilson S (Eds). Non-neoplastic disorders of bone marrow. Atlas of non-tumor pathology. AFIP, 2008.

Swerdlow, S.H., Campo, E., Harris, N.L., Jaffe, E., Pileri, S.A., Stein, H., Thiele, J., Vardiman, J. (Eds.): WHO Classification of Tumours Pathology of Haematopoietic and Lymphoid Tumours, IARC, Lyon, 2008.

Keren DF, McCoy JP Jr, Carey JL (Eds.): Flow Cytometry in Clinical Diagnosis, 4rd Edition, ASCP, 2007.

Bain, BJ, Clark, DM, Lampert, IA, Wilkins, BS. Bone Marrow Pathology, 3rd Edition, Blackwell Science, 2001.

Kjeldsberg CR: Practical Diagnosis of Hematologic Disorders, 4th Edition, ASCP, 2006.

Leonard, D Diagnostic Molecular Pathology (Volume 41 in the series “Major Problems in Pathology”), Saunders, 2003.

Stramatoyannopoulos M, Perlmutter V. Molecular Basis of Blood Diseases, 3rd Edition, W.B. Saunders, 2001.

Additional Resources:

Knowles DM. Neoplastic Hematopathology, 2nd Edition, Lippincott Williams & Wilkins, 2000.

Peterson LC and Brunning RD. Chapter 37. Bone Marrow specimen Processing, pp1391-1406.

Li C-Y and Yam LT. Chapter 38. Cytochemical, Histochemical and Immunohistochemical Analysis of the Bone Marrow

See list of web-based resources at end of manual.

NOTE: Reading is an important component of this rotation. It is recognized that not all of the above resources can be used nor can most be read in entirety. Use of electronic and other resources to find and read up-to-date journal articles is also critical.

General Trainee Responsibilities during Bone Marrow Rotation

Adequate preparation of a bone marrow prior to sign out includes:

1. Aspirate smears are usually available the day before the biopsy is processed (i.e. the

day before sign-out). Ideally cases should be scanned the day before sign-out in order to select appropriate cases in which trainees will be expected to assume a greater degree of responsibility – please coordinate with your attending. On these cases, please do your own differential counts to see how they compare with the technologists’ counts on the next day. Particularly once you have some experience, the differentials should be on the more interesting/difficult cases. Contact physician if necessary (e.g., if after review with staff pathologists, a new acute leukemia is seen). Trainees will have increasing responsibility for independent preview, as they are more experienced.

2. Obtain sufficient history from computer, chart or physician’s office to understand reason

for marrow being performed and to understand any coexistent disease process, drug usage, exogenous toxins, etc. which might affect bone marrow interpretation. Look up any appropriate laboratory data such as folate, B12, and iron (plus TIBC) in anemias or macrocytosis, results of SPEP, UPEP, and immunofixation in evaluation of plasma cell disorders. If possible, this should be obtained prior to initial review with staff pathologist. The technologist’s history may or may not be sufficient.

3. Preview of peripheral blood smear, marrow aspirate smears and biopsies on all

assigned cases.

4. Gather and interpret any ancillary studies which have been performed such as flow cytometry.

5. Review prior marrow and surgical pathology specimens where appropriate (e.g.

leukemic marrow case where looking for residual/recurrent disease, extent of prior disease in follow-up of plasma cell neoplasia).

6. Write down description and diagnosis in pencil on template or indicate agreement or

disagreement with technologist’s comments with a check mark or other notation. .Discuss the format of bone marrow report with the staff pathologist on service.

7. In consultation with staff pathologist, dictate reports either upon completion of sign-out or after each case. Please use whatever method will get the cases out ASAP. See specific guidelines on next page.

8. The staff pathologist may ask you to proof and correct the reports you have dictated. If

you will be doing this, ask the secretary not to send the report to the pathologist’s queue (i.e. do not “final” the report). Trainee should final the report once it is proofed.

9. With increasing experience, fellows will have a more independent role in bone marrow evaluations with increasing responsibility as designated by faculty.

10. Bone marrow report:

Peripheral blood smear should focus on morphologic features of (1) red blood cells, (2) leukocytes and (3) platelets. Any abnormal or atypical features should be described in detail.

Morphologic description of bone marrow should address the following features: Cellularity Presence of abnormal infiltrates (lymphoid aggregates, clusters of

immature myeloid cells, granuloma, metastatic tumor infiltrates, etc.) Myeloid-to-erythroid ratio Maturation of megakaryocytic, erythroid and granulocytic precursors Presence (and severity) of dysplasia Bone trabeculae

Specific Guidelines for Residents and Fellows on Bone Marrow Service

I. Previewing a. Urgent cases that faculty should be informed about without delay:

i. New acute leukemias.

ii. Day 14 status post chemotherapy induction for acute myeloid leukemia.

. b. Please designate number of cells to be counted; generally 500 cell count if there

is any suspicion for a myeloid neoplasm, 300 cell count for lymphoma/myeloma

staging cases.

c. An iron stain should be ordered if there is anemia, microcytosis, macrocytosis, or

elevated RDW.

i. Please order it on the aspirate smears unless there are no spicules.

ii. If there are no spicules, order it on the touch imprint or core biopsy.

iii. Exception: An iron stain is likely not needed for anemia or abnormal indices

during induction or consolidation for acute leukemia.

II. Preparation prior to sign-out

a. When applicable, have the most recent bone marrow report and diagnostic

bone marrow report printed out.

b. If available, diagnostic and most recent bone marrow slides should be

pulled out and reviewed and reports printed

c. When applicable, review the prior diagnosis, pertinent immunophenotype and

cytogenetics.

d. Preview the case, including the flow cytometry.

i. Arrange a time to sign-out with a faculty member so that you will have

enough time for previewing, which is very important in resident education.

ii. Be ready to discuss the case and ask questions.

III. Immunohistochemistry and other studies

a. Order 5-10 blanks to be cut whenever immunohistochemistry studies are

ordered on our bone marrow cases.

b. Order stains through the bone marrow technologists (Audix stain line 412-802-

3273)

c. Please use the table for dictating the results of the immunohistochemistry

studies.

i. Transcriptions know how to format the results in the table

ii. Quick text = “HISTRPT.”

d. Please remember to justify why immunohistochemistry has been performed if

flow has also been performed.

Quick text choices: FLOW/IHC1 or FLOW/IHC2.

IV. Quality assurance is very important

a. Assess the adequacy of aspirate smears and core biopsy: Adequate, suboptimal, or inadequate, using the following criteria below:

Bone Marrow Adequacy Criteria: Biopsy (trephine):

Adequate (A) 15 mm gross length, at least 10 partially preserved intertrabecular areas (40x)

Suboptimal (S) less than 15 mm length, at least 5 partially preserved intertrabecular areas

Inadequate (I) less than 5 mm, fewer than 5 partially preserved intertrabecular areas

Particle/clot:

Adequate (A) at least 10 partially preserved marrow particles/areas (40x) Suboptimal (S) at least 5 partially preserved marrow particles Inadequate (I) fewer than 5 partially preserved marrow particles

Aspirate:

Adequate (A) 3 or more spicules, 300 or more cells Suboptimal (S) 1 or 2 spicules, 100 or more cells Inadequate (I) no spicules, BM diff. cannot be performed (less than 100 cells)

Touch imprint:

Adequate (A) 300 or more cells Suboptimal (S) 100 or more cells, less than 300 Inadequate (I) BM diff. cannot be performed (less than 100 cells)

V. Dictations, proof reading, and final sign-out

a. After the initial review of a case with the hematopathologist, please dictate the report to the best of your ability. Additional studies and final diagnosis can be added later.

b. After you have dictated the final report, proof read it, and then arrange with the faculty how they wish you to proceed. Some would like the slides and paperwork.

c. Faculty specific requests.

Dr. Gibson: For normal flow interpretations, please use “CGR_NEG_BM” and modify appropriately

VI. Wednesday 8:30 am conference

a. The trainee on the adult bone marrow service is responsible for the 3 cases for the Wednesday conference for the following week after sign-out with the faculty member on BM#1 service.

b. If there is a trainee on the pediatric/ATL bone marrow service, then the trainees should determine if that trainee is presenting a pediatric or ATL case.

c. If the trainee(s) cannot meet this expectation, it is his, her or their responsibility to make arrangements with someone, such as the faculty member, so that 3 cases get presented.

d. Discuss the last minute details of your cases to be presented with the responsible faculty member on Monday, two days before the conference. Determine if the faculty member needs to review the digital images or any other details.

VII. Going off service a. Please make it clear to the responsible faculty member what the status of a case

is, what is pending, and where you have put it. b. At the beginning of this last week on service, discuss with the responsible faculty

member who will be presenting at Wednesday 8:30 am conference. In most cases, you will still be able to present your cases even if on another hematopathology service.

Policy for Review of Bone Marrow Aspirates, Particle Preparations and Biopsies

Technologists will screen all smears; assess quality of specimen and quality of stain.

Technologist will inform Trainee or if no trainee, faculty when new marrow aspirates with acute leukemia or day 14 S/P chemotherapy are ready to be reviewed. A worksheet with the CBC data and morphology comments written in should be printed and made available for the review with the aspirate smear and PB smear. In addition a working draft that includes previous cases will be attached. In other cases check review bin in the sign-out room. Trainee/Pathologist will review aspirate smears/cases together with the history and other clinical data on day they are received in the laboratory.

Clinicians performing marrows may also request a marrow differential or iron stain. This will have been noted by the technologist on the form that is used to record what special studies are being requested.

Other useful information 1. To order additional immunohistochemical stains, FISH molecular orders and all other non

stat requests on bone marrow cases call the Audix stain line 412-802-3273 and leave a message. These are routinely picked up during normal working hours.

2. Prior slides:

Bone marrow slides from part of 2009-present are in G325.1.

Bone marrow slides from unknown-part of 2008 are at Iron Mountain.(see table below)

In the Hematology Lab, the peripheral blood slides are kept for 2 weeks and are filed by accession number. The CBC results are in Sunquest/Mysis.

Slides to preview for bone marrow service #1 are placed in G315. There is also a bin for the cases ready for the technologist. Cases ready for sign out are also placed in G315.

Flow reports are tubed to the bone marrow room G325.1 up to 5:15pm. After that, urgent cases are delivered directly to the pathologist

Bone Marrow Rotation Checklist


Orientation with Dr. Swerdlow and Dr. Gibson or his designate.

Reviewed entire ASCP teaching set (Blood Cell Morphology).

Reviewed aspirate smears from teaching set with Bone Marrow Technologist.

Can recognize all normal hematopoietic cell types at all stages of maturation and knows normal bone marrow morphology. Perform peripheral blood and bone marrow differential counts.

Knows phenotype of normal hematopoietic elements.

Confidently can interpret flow cytometry data including histograms.

Knows role of cytogenetics and molecular diagnostic studies in evaluating hematopoietic / lymphoid disorders in bone marrow and blood.

Learned diagnostic criteria using multiparameter approach and clinical implications for each of the following:

Diagnosis/Finding



Read About

MYELOPROLIFERATIVE NEOPLASMS

Chronic myelogenous leukaemia, BCR-ABL1 positive

Chronic neutrophilic leukaemia

Polycythaemia vera

Primary myelofibrosis

Essential thrombocythaemia

Chronic eosinophilic leukaemia, NOS

Myeloproliferative neoplasm, unclassifiable

MYELOID AND LYMPHOID NEOPLASMS WITH EOSINOPHILIA AND ABNORMALITIES OF PDGFRA, PDGFRB OR FGFR1

MYELODYSPLASTIC/MYELOPROLIFERATIVE NEOPLASMS

Chronic myelomonocytic leukaemia

Atypical chronic myeloid leukaemia, BCR-ABL1 negative

Juvenile myelomonocytic leukaemia

Myelodysplastic/myeloproliferative neoplasm, unclassifiable

Refractory anaemia with ring sideroblasts associated with marked thrombocytosis

MYELODYSPLASTIC SYNDROMES

Hypoplastic myelodysplastic syndrome

MDS with fibrosis

Refractory cytopenia with unilineage dysplasia

Refractory anaemia with ring sideroblasts

Refractory cytopenia with multilineage dysplasia

Refractory anaemia with excess blasts

Myelodysplastic syndromes associated with isolated del (5q)

ACUTE MYELOID LEUKEMIA (AML) AND RELATED PRECURSOR NEOPLASMS

AML with recurrent genetic abnormalities

AML (promyelocytic) with t(15;17)(q22;q21); PML-RARA

AML with t(8;21) (q22; q22); RUNX1-RUNX1T1

AML with inv(16) (p13.1q22) or t(16;16) (p13.1;q22); CBFB-MYH11

AML with t(9;11) (q22; q23); MLLT3-MLL

AML with t(6;9) (p23; q34); DEK-NUP214

AML with inv(3) (q21q26.2) or t(3;3) (q221;q26.2); RPN1-EVI1

AML (megakaryoblastic) with t(1;22) (p12;q13); RBM12-MKL1

AML with mutated NPM1

AML with mutated CEBPA

AML with myelodysplasia-related changes

Therapy-related myeloid neoplasms

Acute myeloid leukaemia, NOS

AML with minimal differentiation

AML without maturation

AML with maturation

Acute myelomonocytic leukaemia

Acute monoblastic and monocytic leukaemia

Acute erythroid leukaemia

Acute megakaryoblastic leukaemia

Acute basophilic leukaemia

Acute panmyelosis with myelofibrosis

Blastic plasmacytoid dendritic cell neoplasm

ACUTE LEUKAEMIAS OF AMBIGUOUS LINEAGE

Acute undifferentiated leukaemia

Mixed phenotype acute leukaemias

PRECURSOR LYMPHOID NEOPLASMS

B lymphoblastic leukaemia/lymphoma, NOS

B lymphoblastic leukaemia/lymphoma with recurrent genetic abnormalities

T lymphoblastic leukaemia/lymphoma

Lymphoid leukaemias

Chronic lymphocytic leukemia/small lymphocytic lymphoma

B-cell prolymphocytic leukemia

Hairy cell leukemia

T-cell prolymphocytic leukemia

T-cell large granular lymphocyte leukemia

Aggressive NK-cell leukemia

Adult T-cell leukemia/lymphoma

Plasma cell myeloma

Bone Marrow involvement in lymphoma

Lymphoplasmacytic lymphoma

Marginal zone B-cell lymphomas

Follicular lymphoma

Mantle cell lymphoma

Diffuse large B-cell lymphoma

Intravascular large B-cell lymphoma

Burkitt lymphoma/leukemia

Hepatosplenic T-cell lymphoma

Mycosis fungoides/ Sézary syndrome

Peripheral T-cell lymphoma, unspecified

Angioimmunoblastic T-cell lymphoma

Anaplastic large cell lymphoma

Nodular lymphocyte predominant Hodgkin lymphoma

Classical Hodgkin lymphoma

Other

Mastocytosis

BM in Post-transplant lymphoproliferative disorder

Amyloidosis

Metastatic tumor in bone marrow

BM changes post chemotherapy/transplant/growth factor therapy

Non Neoplastic Disorders

Granulomas in bone marrow and differential diagnosis

HIV associated disease associated bone marrow changes

Autoimmune disease associated bone marrow with increased myelofibrosis

Serous Atrophy

Red Blood Cells

Anemias, NOS

Iron Deficiency

Anemia of chronic disease

B12/folate deficiency

Hemolytic anemia

Aplastic anemia

Erythrocytosis and secondary polycythemia

White Blood Cells

Leukemoid Reaction/Non-Neoplastic Neutrophilia

Neutropenia

Eosinophilia

Basophilia

Monocytosis

Lymphocytosis

Infectious mononucleosis and other viral infection

Megakaryocytes/Platelets

Thrombocytosis

Thrombocytopenia

Autoimmune thrombocytopenic purpura

Thrombotic thrombocytopenic purpura

Infectious disease

Malaria

Babesia

Anaplasmosis

PRESENTED THE FOLLOWING BONE MARROW CASES (Fellows submit presentation in portfolio).

PHB NUMBER DIAGNOSIS

UTILIZED THE FOLLOWING BONE MARROW RESOURCES

A set of cytochemical stains and pb/bm smears is available from the bone

marrow technologists. Individual faculty members also have teaching slides.

“Articles for Residents” black binders. Classic reference articles for classification of leukemia, etc. Located in G323.

Foucar, K Reichard KK and Czuchlewski D. Bone Marrow Pathology, 3nd Edition,

ASCP Press, 2010.

Swerdlow, S.H., Campo, E., Harris, N.L., Jaffe, E., Pileri, S.A., Stein, H., Thiele, J., Vardiman, J. (Eds.): WHO Classification of Tumours Pathology of Haematopoietic and Lymphoid Tumours, 343-349, IARC, Lyon, 2008.

Bain, BJ, Clark, DM, Lampert, IA, Wilkins, BS. Bone Marrow Pathology, 3rd

Edition, Blackwell Science, 2001.


Foucar, K., Viswanatha, D.S., Wilson, C.S., Non-Neoplastic Disorders of Bone

Marrow, American Registry of Pathology, 2008.

There is a peripheral blood and fluid study set that can be checked out from the Hematopathology Secretary (G306).

I have completed the Bone Marrow Checklist. Name __________________________________________ (printed) __________________________________________ (signature) Date __________________________________________

APPENDIX LOCATION OF BONE MARROW RECORDS

5/21/15

CHP UPMC MUH (PRIOR TO MERGER)

SLIDES

REPORTS

SLIDES

REPORTS

SLIDES

REPORTS

1994 – 2008 (PHB08-2859) In Iron mountain

PHB08-2860 to

present : see adult slides locations.

1996-Present: In CoPath Client Server.

Part 2013-Present: PHB (PHB13-842- present) G325.1 PUH Bone Marrow Room.

REPORTS

1990-Present

In Co-path

Client Server.

Starting April, 2009

Surg path reqs stored in the Scaife processing area.

1983-1988 asp 1991-1995 asp and bx:

Iron Mountain. Unknown-1991 bx: MUH

Surgical Pathology files in Iron Mountain.

1990-1995: As described for UPMC

Unknown-part 2013 (PHB13-841) Iron Mountain.

1981-1990: A Stem 6th floor, Microfiche files

1967-1982 asp: Iron Mountain.

Unknown-1990:

BRM

1976-1994: Iron Mountain. Unknown-1976 CHP Pathology (basement)

1930-1938, 1950-1996: BRM

1963-1981: BRM

Forms and Templates for Bone Marrow Service

ADULT BONE MARROW SERVICE REQUEST FORM

PHB13- Date ADDSYNOPTIC Name: Requests:

PB not available Do full PB Diff and review Scan PB for morphology, blasts and abnormal cells Scan PB for blasts and abnormal cells Scan BM smear for tumor Do BM Diff with detailed review of smears

300 cell count 500 cell count

*default is 300 cell differential

Order Iron Stain on biopsy/smear Order the following cytochemical stains: SB PX PAS CAE DBLE (+/-fl) NSE (Acetate Esterase +/- fluoride) NSE (Butyrate Esterase +/- fluoride) Order the following other stains: Stain Specimen Date/Time Tech (Bx,FBM,clot...) _______________________ ________ ___________________ _______________________ ________ ___________________ Molecular: Other:__________________________________________________ Print full report Pull slides Most recent previous BM First diagnostic BM PH__-___________ PH__-___________ _____________________________ Pathologist/Resident #1 or #2 or #3 or CHP Bone Marrow Service --------------------------------------------------------------------------------------------------------------------- Quality Assurance Check:

Satisfactory.

Less than optimal: stain quality:_______________________________

differential count PB _ BM _ : __________

morphology evaluation :______________________

history incomplete/incorrect :__________________

Comment

ADULT BONE MARROW WORKSHEET

OUTSIDE ADULT BONE MARROW WORKSHEET

Technologist: ________________________________________________________________________

Clinical History:

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Medications/Chemotherapy/Growth Factors:______________________________________________

______________________________________________________________________________________

DIAGNOSIS:

Part 1) PERIPHERAL BLOOD -_________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Parts 2&3) BONE MARROW, BIOPSY,(TOUCH IMPRINTS) AND ASPIRATE (AND PARTICLE

PREPARATION)-

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_________________________________________________________________ (See Comment)

COMMENT:_____________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

DESCRIPTION:

PERIPHERAL BLOOD:

The following CBC is from ___/___/___, SLIDE # ___________

CBC Patient Typical Normal Reference Range

. Value (Male/Female)

WBC ____________x10E+9/L (4.40 - 11.3)

RBC ____________x10E+12/L (4.50 - 5.90/4.10 - 5.10)

Hgb ____________g/dl (14.0 - 17.5/12.3 - 15.3)

Hct ____________% (41.5 - 50.4/35.9 - 44.6)

MCV ____________fl (80.0 - 96.0)

MCH ____________pg (27.5 - 33.2)

MCHC ____________gm/dl (33.4 - 35.5)

RDW ____________%

PLT ____________x10E+9/L ( 150 - 450 )

Retic ___________% ( 0.5 - 1.5 )

Retic ___________x10E+12/L (0.025 - 0.075)

Polys ___________% __________(ABS) (1.80 - 7.80)

Bands ___________% __________(ABS) (0.00 - 0.70)

Lymphs ___________% __________(ABS) (1.00 - 4.80)

Atyp. lymph _________% __________(ABS)

Monos ___________% __________(ABS) (0.00 - 0.80)

Eos ___________% __________(ABS) (0.00 - 0.45)

Baso ___________% __________(ABS) (0.00 - 0.20)

Blasts ___________% __________(ABS)

Promyel ___________% __________(ABS)

Myelo ___________% __________(ABS)

Meta ___________% __________(ABS)

NRBC/100 WBC ___________

The peripheral blood smear was reviewed as follows:

______________________________________________________________________________

______________________________________________________________________________

RED BLOOD CELL MORPHOLOGY:

___Acanthocytes, ___Anisocytosis, ___Basophilic Stippling, ___Burr Cells,

___Howell-Jolly Bodies, ___Hypochromia, ___Macrocytes, ___Microcytes,

___Normochromic, ___Normocytic, ___Ovalocytes, ___Poikilocytosis,

___Polychromasia, ___Schistocytes, ___Spherocytes, ___Target Cells, ___Teardrops,

___Unremarkable,

_______________________________________________________________

________________________________________________________________________________

WHITE BLOOD CELL MORPHOLOGY:

_____Auer Rods, _____Blasts, _____Dohle Bodies, _____Hypogranularity,

_____Hypersegmentation, _____Pseudo-Pelger-Huet Anomaly, _____Toxic Granulation,

_____Atypical Lymphocytes, _____Unremarkable, _____Vacuoles _____________________

_________________________________________________________________________________

PLATELETS: are (increased, decreased, adequate) with (clumping, giant forms) seen.

_________________________________________________________________________________

BONE MARROW:

ADEQUACY STATEMENT:

The MARROW ASPIRATE SMEARS are (ADEQUATE, SUBOPTIMAL, INADEQUATE) for

interpretation precluding a differential). ( ___ aspirate smears and _____ touch

imprints reviewed).

The MARROW BIOPSY is (ADEQUATE, SUBOPTIMAL, INADEQUATE) for interpretation.

THE MARROW PARTICLE PREP is (ADEQUATE, INADEQUATE) for interpretation.

“Evaluation of the bone marrow biopsy includes review of an H&E stain as

well as a PAS stain which is done, in part, to highlight the myeloids and

megakaryocytic elements, further evaluate the myeloid:erythroid ratio and

evaluate the underlying bone marrow stroma.”

BONE MARROW differential (_____ cells counted):

Bone Marrow Patient Adult Normal

Differential Value Mean Range

Blast _____________% 1.0 ( 0.0 - 2.0 )

Promyelocyte _____________% 3.0 ( 2.0 - 4.0 )

Myelocyte _____________% 12.0 ( 8.0 - 16.0 )

Metamyelocyte _____________% 17.0 ( 10.0 - 25.0 )

Band _____________% 12.0 ( 9.0 - 18.0 )

PMN _____________% 9.0 ( 7.0 - 14.0 )

Eos Myelo/Meta _____________% 2.0 ( 1.0 - 4.0 )

Eos Band _____________% 1.0 ( 0.0 - 3.0 )

Eos Seg _____________% 1.0 ( 1.0 - 2.0 )

Basophil _____________% 0.0 ( 0.0 - 0.2 )

Monocytes _____________% 1.0 ( 0.0 - 2.0 )

Pronormoblasts _____________% 1.0 ( 0.0 - 1.0 )

Normoblasts _____________% 24.0 ( 16.0 - 32.0 )

Lymphocytes _____________% 16.0 ( 11.0 - 23.0 )

Plasma Cells _____________% 2.0 ( 0.0 - 3.0 )

Other _____________%

Myeloid/Erythroid _____________% 2.4 ( 1.5 - 3.3 )

The MARROW is (mildly, moderately, markedly) (normocellular, hypocellular,

hypercellular)

(_____% cellular). There is stromal injury/chemotherapy effect.

_____________________________________________________________________________________

_____________________________________________________________________________________

The MYELOID/ERYTHROID RATIO is (mildly, moderately, markedly)(increased, decreased,

unremarkable, not evaluable)

_____________________________________________________________________________________

_____________________________________________________________________________________

ERYTHROID MATURATION is (complete, slight, moderate, marked, megaloblastoid,

megaloblastic, asynchronous, with dyserythropoietic forms).

_____________________________________________________________________________________

_____________________________________________________________________________________

MYELOID MATURATION is (complete, slight, moderate, marked, megaloblastoid,

megaloblastic, with dysplastic forms, with pseudo-Pelger-Huet forms, with a left

shift).

_____________________________________________________________________________________

_____________________________________________________________________________________

MEGAKARYOCYTES are (present in, absent) (mildly, moderately, markedly) (increased,

decreased, normal) numbers (with clusters, aggregates, very large aggregates present).

MEGAKARYOCYTES

include (monolobate, hypersegmented, small, non-budding, dysplastic) forms.

____________________________________________________________________________________

____________________________________________________________________________________

STAINABLE IRON is (absent, decreased, present, moderately abundant, abundant) based on

an iron stain performed on the (aspirate smear, biopsy, particle preparation).

There are (no, rare, moderate numbers of, numerous) ringed sideroblasts identified.

No focal lesions are identified. The bony trabeculae are (unremarkable, thinned,

show osteoclastic resorption, osteoblastic rimming, show new bone formation).

____________________________________________________________________________________

____________________________________________________________________________________

ANCILLARY STUDIES:

FLOW/IHC1: Medical necessity justification for the immunohistochemical stains that

were needed in addition to the flow cytometric immunophenotypic studies for the best

diagnosis possible is as follows:

The flow cytometric studies did not define the precise nature of all the cellular

elements of concern in this specimen.




The flow cytometric studies are not clearly representative of all the features

requiring evaluation in this specimen.

ADULT BONE MARROW WORKSHEET

INSIDE ADULT BONE MARROW WORKSHEET

Technologist: ________________________________________________________________________

Clinical History:

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Medications/Chemotherapy/Growth Factors:______________________________________________

______________________________________________________________________________________

DIAGNOSIS:

Part 1) PERIPHERAL BLOOD -_________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Parts 2&3) BONE MARROW, BIOPSY,(TOUCH IMPRINTS) AND ASPIRATE (AND PARTICLE

PREPARATION)-

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_________________________________________________________________ (See Comment)

COMMENT:_____________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

DESCRIPTION:

PERIPHERAL BLOOD:


CBC Patient UPMC-Presbyterian Normal Range


WBC ____________x10E+9/L (3.8 - 10.6)

RBC ____________x10E+12/L (4.13 - 5.57/3.73 - 4.89)

Hgb ____________g/dl (12.9 - 16.9/11.6 - 14.6)

Hct ____________% (38.0 - 48.8/34.1 - 43.3)

MCV ____________fl (82.6 - 97.4)

MCH ____________pg (27.8 - 33.4)

MCHC ____________gm/dl (32.7 - 35.5)

RDW ____________% (11.8 - 15.2)

PLT ____________x10E+9/L ( 156 - 369 )

Retic ___________% ( 0.8 - 2.0/0.8 - 4.0)

Retic ___________x10E+12/L (0.018 - 0.158)

Polys ___________% __________(ABS) (2.24 - 7.68)

Bands ___________% __________(ABS) (0.10 - 0.80)

Lymphs ___________% __________(ABS) (0.80 - 3.65)

Atyp. lymph _________% __________(ABS)

Monos ___________% __________(ABS) (0.30 - 0.90)

Eos ___________% __________(ABS) (0.00 - 0.40)

Baso ___________% __________(ABS) (0.00 - 0.06)

Blasts ___________% __________(ABS)

Promyel ___________% __________(ABS)

Myelo ___________% __________(ABS)

Meta ___________% __________(ABS)

NRBC/100 WBC ___________

The peripheral blood smear was reviewed as follows:

______________________________________________________________________________

______________________________________________________________________________

RED BLOOD CELL MORPHOLOGY:

___Acanthocytes, ___Anisocytosis, ___Basophilic Stippling, ___Burr Cells,

___Howell-Jolly Bodies, ___Hypochromia, ___Macrocytes, ___Microcytes,

___Normochromic, ___Normocytic, ___Ovalocytes, ___Poikilocytosis,

___Polychromasia, ___Schistocytes, ___Spherocytes, ___Target Cells, ___Teardrops,

___Unremarkable, _______________________________________________________________

________________________________________________________________________________

WHITE BLOOD CELL MORPHOLOGY:

_____Auer Rods, _____Blasts, _____Dohle Bodies, _____Hypogranularity,

_____Hypersegmentation, _____Pseudo-Pelger-Huet Anomaly, _____Toxic Granulation,

_____Atypical Lymphocytes, _____Unremarkable, _____Vacuoles _____________________

_________________________________________________________________________________

PLATELETS: are (increased, decreased, adequate) with (clumping, giant forms) seen.

_________________________________________________________________________________

BONE MARROW:

ADEQUACY STATEMENT:

The MARROW ASPIRATE SMEARS are (ADEQUATE, SUBOPTIMAL, INADEQUATE) for

interpretation precluding a differential). (___ aspirate smears and _____ touch

imprints reviewed).

The MARROW BIOPSY is (ADEQUATE, SUBOPTIMAL, INADEQUATE) for interpretation.

THE MARROW PARTICLE PREP is (ADEQUATE, INADEQUATE) for interpretation.

“Evaluation of the bone marrow biopsy includes review of an H&E stain as

well as a PAS stain which is done, in part, to highlight the myeloids and

megakaryocytic elements, further evaluate the myeloid:erythroid ratio and

evaluate the underlying bone marrow stroma.”

BONE MARROW differential (_____ cells counted):

Bone Marrow Patient Adult Normal

Differential Value Mean Range

Blast _____________% 1.0 ( 0.0 - 2.0 )

Promyelocyte _____________% 3.0 ( 2.0 - 4.0 )

Myelocyte _____________% 12.0 ( 8.0 - 16.0 )

Metamyelocyte _____________% 17.0 ( 10.0 - 25.0 )

Band _____________% 12.0 ( 9.0 - 18.0 )

PMN _____________% 9.0 ( 7.0 - 14.0 )

Eos Myelo/Meta _____________% 2.0 ( 1.0 - 4.0 )

Eos Band _____________% 1.0 ( 0.0 - 3.0 )

Eos Seg _____________% 1.0 ( 1.0 - 2.0 )

Basophil _____________% 0.0 ( 0.0 - 0.2 )

Monocytes _____________% 1.0 ( 0.0 - 2.0 )

Pronormoblasts _____________% 1.0 ( 0.0 - 1.0 )

Normoblasts _____________% 24.0 ( 16.0 - 32.0 )

Lymphocytes _____________% 16.0 ( 11.0 - 23.0 )

Plasma Cells _____________% 2.0 ( 0.0 - 3.0 )

Other _____________%

Myeloid/Erythroid _____________% 2.4 ( 1.5 - 3.3 )

The MARROW is (mildly, moderately, markedly) (normocellular, hypocellular,

hypercellular)

(_____% cellular). There is stromal injury/chemotherapy effect.

_____________________________________________________________________________________

_____________________________________________________________________________________

The MYELOID/ERYTHROID RATIO is (mildly, moderately, markedly)(increased, decreased,

unremarkable, not evaluable)

_____________________________________________________________________________________

_____________________________________________________________________________________

ERYTHROID MATURATION is (complete, slight, moderate, marked, megaloblastoid,

megaloblastic, asynchronous, with dyserythropoietic forms).

_____________________________________________________________________________________

_____________________________________________________________________________________

MYELOID MATURATION is (complete, slight, moderate, marked, megaloblastoid,

megaloblastic, with dysplastic forms, with pseudo-Pelger-Huet forms, with a left

shift).

_____________________________________________________________________________________

_____________________________________________________________________________________

MEGAKARYOCYTES are (present in, absent) (mildly, moderately, markedly) (increased,

decreased, normal) numbers (with clusters, aggregates, very large aggregates present).

MEGAKARYOCYTES

include (monolobate, hypersegmented, small, non-budding, dysplastic) forms.

____________________________________________________________________________________

____________________________________________________________________________________

STAINABLE IRON is (absent, decreased, present, moderately abundant, abundant) based on

an iron stain performed on the (aspirate smear, biopsy, particle preparation).

There are (no, rare, moderate numbers of, numerous) ringed sideroblasts identified.

No focal lesions are identified. The bony trabeculae are (unremarkable, thinned,

show osteoclastic resorption, osteoblastic rimming, show new bone formation).

____________________________________________________________________________________

____________________________________________________________________________________

ANCILLARY STUDIES:




The flow cytometric studies did not define the precise nature of all the cellular

elements of concern in this specimen.




The flow cytometric studies are not clearly representative of all the features

requiring evaluation in this specimen.

ANCILLARY STUDIES:

Cytochemical Stains

Histologic Section Immunohistochemistry/In situ Hybridization

CYTOCHEMICAL STAINS Interpretation/Diagnosis (for special tests only/addenda):______ ________________________________________________________________ ________________________________________________________________ Results/Ancillary Studies: Cytochemical stains were performed on: _________________________ The following results were found: Stain Usual Reactivity Results --------------------------------------------------------------------------------------------------------------- Sudan Black gran, mono --------------------------------------------------------------------------------------------------------------- Peroxidase gran, mono ---------------------------------------------------------------------------------------------------------------- PAS diff*-gran, mono block-lymph diff +/- block-abnl RBC ----------------------------------------------------------------------------------------------------------------- CAE CAE-gran, mast ----------------------------------------------------------------------------------------------------------------- NSE NSE-mono, mega NSE Positivity Was / was not inhibited by fluoride --------------------------------------------------------------------------------------------------------------------

DAY 14 BONE MARROW WORKSHEET

Technologist: _________________________________________________________________

Clinical History:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Medications/Chemotherapy/Growth Factors:__________________________________________

__________________________________________________________________________________

Specimen adequacy: Aspirate: Adequate/Suboptimal/Inadequate/Not evaluable

Touch imprint: Adequate/Suboptimal/Inadequate/Not evaluable

Biopsy: Adequate/Suboptimal/Inadequate/Not evaluable

Particle/clot: Adequate/Suboptimal/Inadequate/Not evaluable

Bone marrow blasts: Absent/Present ( %)/Not evaluable

Counted on aspirate/touch imprint:

Cells counted (100, 200, 300, 500, other)

Marrow cellularity: ( %)

Peripheral blood blasts: Absent/Present( %)/Slide not available.

Cells counted(100,200)

Marrow regeneration:

Erythropiesis: Absent/Rare/Present/Not evaluable

Granulopoiesis: Absent/Rare/Present/Not evaluable

Megakaryopoiesis: Absent/Rare/Present/Not evaluable

Additional morphologic findings:

Clusters of immature cells

Lymphoid aggregate(s)

Granuloma(s)

Other:

Immunohistochemical stains performed to better assess marrow findings:

CD34

CD117

TDT

Other

“Medical necessity justification for the immunohistochemical stains that were needed in

addition to the flow cytometric immunophenotypic studies for the best diagnosis possible is

as follows: The flow cytometric studies did not define the precise nature of all the

cellular elements of concern in this specimen”.

Cytochemical stains performed to better assess marrow findings:

Myeloperoxidase

Non-specific (Butyrate) esterase

This report is based on morphologic evaluation of submitted bone marrow specimen and the

following completed ancillary studies:

Immunohistochemical stains

Cytochemical stains

Flow cytometric analysis (separate report attached)

Classical cytogenetic (karyotypic) analysis (separate report

attached)

Cytogenetic FISH analysis (separate report attached)

Molecular analysis (separate report attached)

Other:

The following studies are pending with results to follow:

Immunohistochemical stains

Cytochemical stains

Flow cytometric analysis

Classical cytogenetic (karyotypic) analysis

Cytogenetic FISH analysis

Molecular analysis

Other:

2 bone marrow aspirate smears and 1 touch prep reviewed.

“Evaluation of the bone marrow biopsy includes review of an H&E stain as well as a PAS

stain which is done, in part, to highlight the myeloids and megakaryocytic elements, further

evaluate the myeloid: erythroid ratio and evaluate the underlying bone marrow stroma”.


CBC Patient UPMC-Presbyterian Normal Range


WBC ___________ x10E+9/L (3.8 - 10.6)

RBC ___________ x10E+12/L (4.13 - 5.57/3.73 - 4.89)

Hgb ____________g/dl (12.9 - 16.9/11.6 - 14.6)

Hct ____________% (38.0 - 48.8/34.1 - 43.3)

MCV ___________ fl (82.6 - 97.4)

MCH __________ pg (27.8 - 33.4)

MCHC __________ gm/dl (32.7 - 35.5)

RDW __________ % (11.8 - 15.2)

PLT ___________ x10E+9/L ( 156 - 369 )

Retic ___________% ( 0.8 - 2.0/0.8 - 4.0)

Retic ___________x10E+12/L (0.018 - 0.158)

Polys __________% __________(ABS) (2.24 - 7.68)

Bands ___________% __________(ABS) (0.10 - 0.80)

Lymphs ___________% __________(ABS) (0.80 - 3.65)

Atyp. lymph _________% __________(ABS)

Monos ___________% __________(ABS) (0.30 - 0.90)

Eos __________% __________(ABS) (0.00 - 0.40)

Baso __________% __________(ABS) (0.00 - 0.06)

Blasts _________% __________(ABS)

Promyel __________% __________(ABS)

Myelo __________% __________(ABS)

Meta __________% __________(ABS)

NRBC/100 WBC __________

Recommendations for Consistent Terminology in Hematopathology Reports

1. Use the 2008 WHO Classification (see the monograph)

2. Leukemic follow-up marrows

a. History should always state: Day status post chemotherapy (or status post transplant) for abbreviated disease name e.g. AML, promyelocytic

i. If time unknown, delete “day .”

*Remember day status post chemotherapy refers to days following initiation of therapy.

A. Preferably a similar statement should also be in the diagnosis following the initial diagnostic line

e.g.

Bone marrow, biopsy and aspirate-- A. Markedly hypocellular marrow with chemotherapy effect

B. (Day 7 status post chemotherapy for AML).

B. If history of leukemia is remote, history (and if desired, diagnosis) should state:

“Status post previous diagnosis of _____________________”.

3. Whenever appropriate, state, in comment, how the marrow compares to the immediate previous

one and give the previous marrow number; e.g., “compared to the patient’s previous marrow

(PHB11-XXXX), blasts are not increased.”

4. Whenever any ancillary studies or special stains are reported, be sure to include an interpretation

and not just a statement of the result. On cases without histologic material, be sure to dictate an

interpretation including a summary of the results, which will be typed in the space where diagnosis

usually goes.

For example, if an addendum is issued with the results of a reticulin stain, do not include just, “The reticulin stain shows a marked increase in reticulin fibers”, also an interpretation (i.e. “This strongly supports the diagnosis in this case of a myeloproliferative neoplasm”).

5. Abnormal plasma cell proliferations should be given as specific a diagnosis as possible.

A. Plasma cell myeloma (use if possible). B. Plasma cell neoplasm (if definite neoplasm, but uncertain if myeloma). C. Plasmacytosis (with qualifier if the diagnosis of a neoplasm cannot be made). D. Plasmacytoma (a non-myeloma plasma cell neoplasm). E. Remember, plasma cell dyscrasia includes non-neoplastic disorders as well as plasma cell

neoplasms.

Case number:___________________________ Resident Bone Marrow Differential count Worksheet (_______ cells counted)

Blasts

Promyelocytes

Myelocytes

Metamyelocytes

Bands/Seg Neutrophils

Erythroid cells

Lymphocytes

Eosinophils

Basophils

Monocytes

Plasma cells

Myeloid:erythroid ratio

Signature____________________________________________________ Date: ___________________________

Pathologist initials ____________

Protocol for the Examination of Specimens From Patients With Hematopoietic Neoplasms Involving the Bone Marrow

Based on AJCC/UICC TNM, 7th Edition Protocol web posting date: June 2012

Procedures

Bone marrow aspiration

Bone marrow core (trephine) biopsy

Authors

Jerry W. Hussong, MD, DDS, FCAP*

Cedars-Sinai Medical Center, Los Angeles, California

Daniel A. Arber, MD

Stanford University School of Medicine, Stanford, California

Kyle T. Bradley MD, MS, FCAP

Emory University Hospital, Atlanta, Georgia

Michael S. Brown, MD, FCAP

Yellowstone Pathology Institute Inc, Billings, Montana

Chung-Che Chang, MD, PhD, FCAP

The Methodist Hospital, Houston, Texas

Monica E. de Baca, MD, FCAP

Physicians Laboratory Ltd, Sioux Falls, South Dakota

David W. Ellis, MBBS, FRCPA

Flinders Medical Centre, Bedford Park, South Australia

Kathryn Foucar, MD, FCAP

University of New Mexico, Albuquerque, New Mexico

Eric D. Hsi, MD, FCAP

Cleveland Clinic Foundation, Cleveland, Ohio

Elaine S. Jaffe, MD

National Cancer Institute, Bethesda, Maryland

Michael Lill, MB, BS, FRACP, FRCPA


Stephen P. McClure, MD

Presbyterian Pathology Group, Charlotte, North Carolina

L. Jeffrey Medeiros, MD, FCAP

MD Anderson Cancer Center, Houston, Texas

Sherrie L. Perkins, MD, PhD, FCAP

University of Utah Health Sciences Center, Salt Lake City, Utah

For the Members of the Cancer Committee, College of American Pathologists

* Denotes the primary and senior author. All other contributing authors are listed alphabetically.

Surgical Pathology Cancer Case Summary

Protocol web posting date: June 2012 BONE MARROW: Aspiration, Core (Trephine) Biopsy

Select a single response unless otherwise indicated.

Specimen (select all that apply) (Note A)

___ Peripheral blood smear ___ Bone marrow aspiration ___ Bone marrow aspirate clot (cell block) ___ Bone marrow core (trephine) biopsy ___ Bone marrow core touch preparation (imprint) ___ Other (specify): ___________________________ ___ Not specified

Procedure (select all that apply) ___ Aspiration ___ Biopsy ___ Other (specify): ___________________________ ___ Not specified

Aspiration Site (if performed) (select all that apply) (Note B)

___ Right posterior iliac crest ___ Left posterior iliac crest ___ Sternum ___ Other (specify): ___________________________ ___ Not specified

Biopsy Site (if performed) (select all that apply) (Note B)

___ Right posterior iliac crest ___ Left posterior iliac crest ___ Other (specify): ___________________________ ___ Not specified

Histologic Type (Note C)

Note: The following is a partial list of the 2008 World Health Organization (WHO) classification1 and includes those neoplasms

seen in bone marrow specimens.

___ Histologic type cannot be assessed Myeloproliferative Neoplasms ___ Chronic myelogenous leukemia, BCR-ABL1 positive

___ Chronic neutrophilia leukemia ___ Polycythemia vera ___ Primary myelofibrosis ___ Essential thrombocythemia ___ Chronic eosinophilic leukemia, not otherwise specified (NOS) ___ Mastocytosis (specify type): ______________________ ___ Myeloproliferative neoplasm, unclassifiable Myeloid and Lymphoid Neoplasms With Eosinophilia and Abnormalities of PDGFRA, PDGFRB and FGFR1 ___ Myeloid or lymphoid neoplasm with PDGFRA rearrangement ___ Myeloid neoplasm with PDGFRB rearrangement ___ Myeloid or lymphoid neoplasm with FGFR1 abnormalities Myelodysplastic/Myeloproliferative Neoplasms ___ Chronic myelomonocytic leukemia ___ Atypical chronic myeloid leukemia BCR-ABL1 negative ___ Juvenile myelomonocytic leukemia ___ Myelodysplastic/myeloproliferative neoplasm, unclassifiable ___ Refractory anemia with ring sideroblasts associated with marked thrombocytosis Myelodysplastic Syndromes ___ Refractory anemia ___ Refractory neutropenia ___ Refractory thrombocytopenia ___ Refractory anemia with ring sideroblasts ___ Refractory cytopenia with multilineage dysplasia ___ Refractory anemia with excess blasts ___ Myelodysplastic syndrome associated with isolated del(5q) ___ Myelodysplastic syndrome, unclassifiable ___ Refractory cytopenia of childhood Acute Myeloid Leukemia (AML) With Recurrent Genetic Abnormalities ___ AML with t(8;21)(q22;q22); RUNX1-RUNX1T1 ___ AML with inv(16)(p13.1q22) or t(16;16)(p13.1;q22); CBFB-MYH11 ___ Acute promyelocytic leukemia with t(15;17)(q22;q12); PML-RARA ___ AML with t(9;11)(p22;q23); MLLT3-MLL ___ AML with t(6;9)(p23;q34); DEK-NUP214 ___ AML with inv(3)(q21q26.2) or t(3;3)(q21;q26.2); RPN1-EVI1 ___ AML (megakaryoblastic) with t(1;22)(p13;q13); RBM15-MKL1 ___ AML with mutated NPM1 ___ AML with mutated CEBPA Acute Myeloid Leukemia With Myelodysplasia-Related Changes (select all that apply) ___ Multilineage dysplasia ___ Prior myelodysplastic syndrome ___ Myelodysplasia-related cytogenetic abnormalities Therapy-Related Myeloid Neoplasms ___ Therapy-related AML ___ Therapy-related myelodysplastic syndrome ___ Therapy-related myelodysplastic/myeloproliferative neoplasm Acute Myeloid Leukemia, NOS ___ AML with minimal differentiation ___ AML without maturation

___ AML with maturation

___ Acute myelomonocytic leukemia ___ Acute monoblastic/monocytic leukemia ___ Acute erythroid leukemia ___ Acute megakaryocytic leukemia ___ Acute basophilic leukemia ___ Acute panmyelosis with myelofibrosis ___ AML, NOS# Myeloid Proliferations Related to Down Syndrome

___ Transient abnormal myelopoiesis ___ Myeloid leukemia associated with Down syndrome Acute Leukemias of Ambiguous Lineage

___ Acute undifferentiated leukemia ___ Mixed phenotype acute leukemia with t(9;22)(q34;q11.2); BCR-ABL1 ___ Mixed phenotype acute leukemia with t(v;11q23); MLL rearranged ___ Mixed phenotype acute leukemia, B/myeloid, NOS ___ Mixed phenotype acute leukemia, T/myeloid, NOS ___ Mixed phenotype acute leukemia, NOS, rare types (specify type): _____________ ___ Natural killer (NK) cell lymphoblastic leukemia/lymphoma Other Myeloid Leukemias ___ Blastic plasmacytoid dendritic cell neoplasm Precursor Lymphoid Neoplasms ___ B lymphoblastic leukemia/lymphoma, NOS

#

___ B lymphoblastic leukemia/lymphoma with t(9;22)(q34;q11.2); BCR-ABL1 ___ B lymphoblastic leukemia/lymphoma with t(v;11q23); MLL rearranged ___ B lymphoblastic leukemia/lymphoma with t(12;21)(p13;q22); TEL-AML1 (ETV6-RUNX1) ___ B lymphoblastic leukemia/lymphoma with hyperdiploidy ___ B lymphoblastic leukemia/lymphoma with hypodiploidy (hypodiploid ALL) ___ B lymphoblastic leukemia/lymphoma with t(5;14)(q31;q32); IL3-IGH ___ B lymphoblastic leukemia/lymphoma with t(1;19)(q23;p13.3); E2A-PBX1 (TCF3-PBX1) ___ T lymphoblastic leukemia/lymphoma

Mature B-Cell Neoplasms

___ Chronic lymphocytic leukemia/small lymphocytic lymphoma ___ B-cell prolymphocytic leukemia ___ Splenic B-cell marginal zone lymphoma ___ Hairy cell leukemia ___ Splenic B-cell lymphoma/leukemia, unclassifiable ___ Splenic diffuse red pulp small B-cell lymphoma ___ Hairy cell leukemia-variant

___ Lymphoplasmacytic lymphoma ___ Plasma cell myeloma ___ Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) ___ Follicular lymphoma ___ Mantle cell lymphoma ___ Diffuse large B-cell lymphoma (DLBCL), NOS ___ T cell/histiocyte-rich large B-cell lymphoma ___ Primary cutaneous DLBCL, leg type

___ Epstein-Barr virus (EBV)-positive DLBCL of the elderly ___ DLBCL associated with chronic inflammation ___ Lymphomatoid granulomatosis ___ Anaplastic lymphoma kinase (ALK)-positive large B-cell lymphoma ___ Plasmablastic lymphoma ___ Large B-cell lymphoma arising in HHV8-associated multicentric Castleman disease ___ Burkitt lymphoma ___ B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma and

Burkitt lymphoma ___ B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma and

classical Hodgkin lymphoma

___ B-cell lymphoma, NOS ___ Other (specify): ____________________________ Mature T- and NK-cell Neoplasms

___ T-cell lymphoma, subtype cannot be determined (Note: not a category within the WHO classification)

___ T-cell prolymphocytic leukemia ___ T-cell large granular lymphocytic leukemia ___ Chronic lymphoproliferative disorder of NK cells ___ Aggressive NK-cell leukemia ___ Adult T-cell leukemia/lymphoma ___ Extranodal NK/T-cell lymphoma, nasal type ___ Enteropathy-associated T-cell lymphoma ___ Hepatosplenic T-cell lymphoma ___ Mycosis fungoides ___ Peripheral T-cell lymphoma, NOS ___ Angioimmunoblastic T-cell lymphoma ___ Anaplastic large cell lymphoma, ALK-positive ___ Anaplastic large cell lymphoma, ALK-negative Hodgkin Lymphoma ___ Nodular lymphocyte predominant Hodgkin lymphoma ___ Classical Hodgkin lymphoma Histiocytic and Dendritic Cell Neoplasms ___ Histiocytic sarcoma ___ Langerhans cell histiocytosis ___ Langerhans cell sarcoma ___ Interdigitating dendritic cell sarcoma ___ Follicular dendritic cell sarcoma ___ Disseminated juvenile xanthogranuloma ___ Histiocytic neoplasm, NOS Posttransplant Lymphoproliferative Disorders (PTLD) ## Early lesions: ___ Plasmacytic hyperplasia ___ Infectious mononucleosis-like PTLD ___ Polymorphic PTLD ___ Monomorphic PTLD (B- and T/NK-cell types)

Specify subtype: ________________________

___ Classical Hodgkin lymphoma type PTLD### ___ Other (specify): ____________________________ Note: Italicized histologic types denote provisional entities in the 2008 WHO classification.

# An initial diagnosis of “AML, NOS” or “B lymphoblastic leukemia/lymphoma, NOS” may need to be given before the cytogenetic

results are available or for cases that do not meet criteria for other leukemia subtypes.

## These disorders are listed for completeness, but not all of them represent frank lymphomas.

### Classical Hodgkin lymphoma type PTLD can be reported using either this protocol or the separate College of American

Pathologists protocol for Hodgkin lymphoma.2

+ Additional Pathologic Findings

+ Specify: _______________________________________

+ Cytochemical/Special Stains (Note D)

+ ___ Performed + Specify stains and results: __________________________________ ______________________________________________________ + ___ Not performed

Immunophenotyping (flow cytometry and/or immunohistochemistry) (Note E)

___ Performed, see separate report: ___________________ ___ Performed Specify method(s) and results: ______________________________

_____________________________________________________ ___ Not performed Cytogenetic Studies (Note F) ___ Performed, see separate report: ___________________ ___ Performed Specify method(s) and results: ______________________________ _____________________________________________________ ___ Not performed + Fluorescence In Situ Hybridization (Note F)

+ ___ Performed, see separate report: ___________________ + ___ Performed + Specify method(s) and results: ______________________________ _____________________________________________________ + ___ Not performed

+ Molecular Genetic Studies (Note F)

+ ___ Performed, see separate report: ___________________ + ___ Performed Specify method(s) and results: ______________________________ _____________________________________________________ + ___ Not performed + Comment(s) + Data elements preceded by this symbol are not required. However, these elements may be

clinically important but are not yet validated or regularly used in patient management.

Explanatory Notes

A. Specimen Complete evaluation of hematopoietic disorders involving the bone marrow requires integration of multiple pieces of data, including the clinical history, pertinent laboratory studies (eg, complete blood count [CBC], serum lactate dehydrogenase [LDH], and beta-2-microglobulin levels, serum protein electrophoresis, and immunofixation results), and a satisfactory peripheral blood smear and bone marrow specimen. In most instances, this requires receiving a peripheral blood smear, bone marrow aspirate specimen, an aspirate clot section (cell block), and a bone marrow core biopsy.3 Touch preparations (imprints) of the biopsy specimen are also very helpful. The World Health Organization (WHO) classification recommends performing a 200-cell differential count on peripheral blood smears and a 500-cell differential count on bone marrow aspirate specimens in the evaluation of hematopoietic disorders.1 This will allow adequate evaluation of the cellular elements within the peripheral blood and bone marrow. In addition, submission of bone marrow (usually aspirate) material for flow cytometry immunophenotyping, cytogenetic studies, fluorescence in situ hybridization (FISH), and molecular studies is often necessary. The guidelines that follow are suggested for handling of bone marrow specimens:

The number of stained and unstained peripheral blood, bone marrow aspirate, and bone marrow core biopsy touch preparation smears should be recorded.

The length of the bone marrow core biopsy(s) should be recorded.

For conventional cytogenetic studies, a bone marrow aspirate specimen received in a sodium heparin tube is ideal, but fresh specimens submitted in saline or RPMI transport medium is sufficient.

For immunophenotyping by flow cytometry, a bone marrow aspirate specimen received in an ACD tube (yellow top tube) or EDTA tube (lavender top tube) is preferred.

Bone marrow core biopsy specimens require decalcification, and care must be taken not to under- or over-decalcify the specimen, as it will impact the ability to cut and interpret the histologic sections and may interfere with immunohistochemical staining. Formic acid decalcification procedures can also degrade DNA, whereas EDTA decalcification may allow for preservation of DNA for polymerase chain reaction (PCR) studies. EDTA decalcification, however, is slower than acid decalcification techniques.

Fixation: o Zinc formalin or B5 fixatives produce superior cytologic detail but are not suitable for

DNA extraction and impair some immunostains (eg, CD30). B5 has the additional limitation of requiring proper hazardous-materials disposal.

o Formalin fixation is preferable in many situations, as it allows for many ancillary tests such as molecular/genetic studies, in-situ hybridization, and immunophenotyping.

o Over-fixation (ie, more than 24 hours in formalin, more than 4 hours in zinc formalin or B5) should be avoided for optimal immunophenotypic reactivity.

Care must be taken to ensure that high-quality specimens and sections are obtained for each bone marrow specimen. Often this requires working hand-in-hand with clinical colleagues to achieve this goal. In addition to being used for the diagnosis of primary hematopoietic disorders, bone marrow examination is often utilized as part of the pathologic staging of many hematopoietic neoplasms, including Hodgkin and non-Hodgkin lymphomas.3-5 Bone marrow involvement identified within staging biopsy specimens typically indicates stage IV disease within the Ann Arbor staging system utilized by the American Joint Committee on Cancer (AJCC)6 and the International Union Against Cancer (UICC).7 For multiple myeloma, the Durie-

Salmon staging system is recommended by the AJCC.8 Both staging systems are shown below. In pediatric patients, the St. Jude staging system is commonly used.9

AJCC/UICC Staging for Non-Hodgkin Lymphomas Stage I Involvement of a single lymph node region (I), or localized involvement of a

single extralymphatic organ or site in the absence of any lymph node involvement (IE).#, ##

Stage II Involvement of 2 or more lymph node regions on the same side of the diaphragm (II), or localized involvement of a single extralymphatic organ or site in association with regional lymph node involvement with or without involvement of other lymph node regions on the same side of the diaphragm (IIE).##,###

Stage III Involvement of lymph node regions on both sides of the diaphragm (III), which also may be accompanied by extralymphatic extension in association with adjacent lymph node involvement (IIIE) or by involvement of the spleen (IIIS) or both (IIIE+S).##,###,^

Stage IV Diffuse or disseminated involvement of 1 or more extralymphatic organs, with or without associated lymph node involvement; or isolated extralymphatic organ involvement in the absence of adjacent regional lymph node involvement, but in conjunction with disease in distant site(s). Stage IV includes any involvement of the liver, bone marrow, or nodular involvement of the lung(s) or cerebral spinal fluid. ##,###,^

# Multifocal involvement of a single extralymphatic organ is classified as stage IE and not stage IV. ## For all stages, tumor bulk greater than 10 to 15 cm is an unfavorable prognostic factor.

### The number of lymph node regions involved may be indicated by a subscript: eg, II3. For

stages II to IV, involvement of more than 2 sites is an unfavorable prognostic factor. ^ For stages III to IV, a large mediastinal mass is an unfavorable prognostic factor. Note: Direct spread of a lymphoma into adjacent tissues or organs does not influence classification of stage.

AJCC/UICC Staging for Plasma Cell Myeloma Stage I Hemoglobin greater than 10.0 g/dL (100 g/L)

Serum calcium 12 mg/dL or less (3.0 mmol/L) Normal bone x-rays or a solitary bone lesion

IgG less than 5 g/dL (50 g/L) IgA less than 3 g/dL (30 g/L) Urine M-protein less than 4 g/24 hours

Test US SI

Hgb >10.0g/dL >100 g/L

Serium calcium 12 mg/dL or less 3.0 mmol/L or less

IgG < 5g/dL <50 g/L

IgA <3 g/dL <30 g/L

Stage III One or more of the following are included:

Hemoglobin less than 8.5 g/dL (85 g/L) Serum calcium greater than 12 mg/dL (3.0 mmol/L) Advanced lytic bone lesions IgG greater than 7 g/dL (70 g/L) IgA greater than 5 g/dL (50 g/L) Urine M-protein greater than 12 g/24 hours

Test US SI

Hemoglobin <8.5 g/dL <85 g/L

Serium calcium >12 mg/dL >3.0 mmol/L

IgG >7g/dL >70 g/L

IgA >5 g/dL >50 g/L

Stage II Disease fitting neither stage I nor stage III Note: Patients are further classified as (A) serum creatinine less than 2.0 mg/dL (177 mmol/L), or (B) serum creatinine 2.0 mg/dL (177 mmol/L) or greater. The median survival for stage IA disease is about 5 years, and that for stage IIIB disease is 15 months. These predicted survivals, however, may underestimate expected survival for these patient populations with modern therapy.

B. Aspiration/Biopsy Site Bone marrow sampling (aspiration and trephine core biopsy) is usually performed at the posterior iliac crest.3 Aspirations and biopsies may be unilateral or bilateral, depending on the indication for the bone marrow biopsy as well as clinician preference. Rarely, a sternal aspiration may be performed if only a bone marrow aspirate specimen is necessary. Sternal aspirations should only be considered as a last resort and should be performed only by persons with extensive experience with this procedure. Occasionally, the anterior iliac crest or tibia may be the site of the biopsy, depending on patient age and other unique characteristics of the patient.

C. Histologic Type This protocol recommends assigning histologic type based on the WHO classification of lymphoid neoplasms.1 Originally published in 2001 and revised and updated in 2008, this classification incorporates the morphologic, immunophenotypic, cytogenetic, and molecular findings into the final diagnosis. Whereas histologic examination remains of paramount importance, many neoplasms will require the use of these ancillary studies to arrive at the correct diagnosis.10-15 It may not be possible to provide a specific lymphoma diagnosis with bone marrow examination, particularly for patients in whom the bone marrow is the first identified site of involvement. Some of the entities provided in the case summary may be extremely uncommon in the bone marrow or may have not been described but are listed for completeness.

D. Cytochemical/Special Stains Numerous cytochemical or special stains may be utilized in the diagnosis of hematopoietic neoplasms involving the bone marrow.3 An iron (Prussian blue) stain is paramount in the evaluation of myelodysplastic syndromes and some myeloproliferative disorders. A reticulin stain is necessary for the diagnosis of some myeloproliferative disorders but may be valuable in evaluation of numerous other disorders such as hairy cell leukemia. Cytochemical stain for

myeloperoxidase is rapid, convenient, and helpful for the assessment of myeloid neoplasms. Cytochemical stains for leukocyte alkaline phosphatase, and naphthol-ASD chloroacetate esterase provide information related to cell origin or specific disease states. Cytochemical stains, however, are no longer required for the diagnosis of most disorders.

E. Immunophenotyping by Flow Cytometry and/or Immunohistochemistry Immunophenotyping of bone marrow specimens can be performed by flow cytometry10 or immunohistochemistry.11 Each has advantages and disadvantages. Flow cytometry is rapid (hours), quantitative, and allows multiple antigens to be evaluated on the same cell simultaneously. Flow cytometry may also allow for the detection of minimal residual disease, especially in situations in which there is a unique expression pattern. Antigen reactivity, however, cannot be correlated with architecture or cytologic features. In patients from whom a dry tap is obtained, an additional bone marrow core biopsy submitted fresh in transport medium can be disaggregated and utilized for flow cytometry immunophenotyping. Immunohistochemistry requires hours/days to perform, quantitation is subjective, but importantly it allows correlation of antigen expression with architecture and cytology. Not all antibodies are available for immunohistochemistry, particularly in fixed tissues, but one of its advantages is that it can be performed on archival tissue. Both techniques can provide diagnostic, prognostic, and therapeutic information. Documentation of expression of antigens such as CD20, CD33, and CD52 by the neoplastic population can aid the clinician in selection of potential therapeutic options such as monoclonal antibody therapy. The specific immunophenotypes for individual hematopoietic disorders involving the bone marrow are readily available within the WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues as well as many other hematopathology textbooks.1,3,5 F. Cytogenetic and Molecular Genetic Studies Within the WHO classification of hematopoietic disorders, significant emphasis has been placed on cytogenetic and molecular genetic studies. More than ever before, specific cytogenetic findings are helpful for the diagnosis of specific neoplasms and disease states.12-16 In fact, many acute leukemias are currently defined based upon their specific cytogenetic abnormalities.1 Given the importance now placed upon knowing the cytogenetic or molecular results (as determined by karyotyping, FISH, or PCR results) it is of paramount importance that care is taken to evaluate the need for these studies at the time of biopsy. FISH studies can be also performed on air-dried unfixed slides, and in some cases DNA can be scraped off air-dried unfixed slides for molecular studies. Since karyotyping requires growing viable cells in culture, it is necessary to submit fresh specimens promptly to help ensure the best opportunity for a successful study.

References 1. Swerdlow S, Campo E, Harris N, Jaffe E, et al, eds. WHO Classification of Tumours of

Haematopoietic and Lymphoid Tissues. Geneva, Switzerland: WHO Press; 2008. 2. Hussong JW, Arber DA, Bradley KT, et al. Protocol for the examination of specimens

from patients with Hodgkin lymphoma. In: Reporting on Cancer Specimens: Case Summaries and Background Documentation. Northfield, IL: College of American Pathologists; 2009.

3. Foucar K, ed. Bone Marrow Pathology. Chicago, IL: ASCP Press; 2001. 4. Zhang Q, Foucar K. Bone marrow involvement by Hodgkin and non-Hodgkin

lymphomas. Hematol Oncol Clin North Am. 2009;23(4):873-902. 5. Hsi E, Goldblum J, eds. Hematopathology. Philadelphia, PA: Churchill Livingstone

Elsevier; 2007.

6. Lymphoid neoplasms. In: Edge SB, Byrd DR, Carducci MA, Compton CC, eds. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer; 2009.

7. Sobin LH, Gospodarowicz M, Wittekind Ch, eds. UICC TNM Classification of Malignant Tumours. 7th ed. New York, NY: Wiley-Liss; 2009.

8. Durie B, Salmon S. A clinical staging system for multiple myeloma: correlation of measured myeloma mass with presenting clinical features, response to treatment, and survival. Cancer. 1975;36(3):842-854.

9. Cairo et al. Non-Hodgkin’s lymphoma in children. In: Kufe P, Weishelbuam R, et al, eds. Cancer Medicine. 7th ed. London: BC Decker; 2006:1962-1975.

10. Craig F, Foon K. Flow cytometric immunophenotyping for hematologic neoplasms. Blood. 2008;111(8):3941-3967.

11. Jaffe E, Banks P, Nathwani B, et al. Recommendations for the reporting of lymphoid neoplasms: a report from the Association of Directors of Anatomic and Surgical Pathology. Mod Pathol. 2004;17(1):131-135.

12. Bagg A. Molecular diagnosis in lymphomas. Curr Oncol Rep. 2004;6(5):369-379. 13. Merker J, Arber D. Molecular diagnostics of non-Hodgkin lymphoma. Expert Opin Med

Diagn. 2007;1(1):47-63. 14. Bagg A. Role of molecular studies in the classification of lymphoma. Expert Rev Mol

Diagn. 2004;4(1):83-97. 15. Sen F, Vega F, Medeiros LJ. Molecular genetic methods in the diagnosis of hematologic

neoplasms. Semin Diagn Pathol. 2002;19(2):72-93. 16. Weinberg O, Seetharam M, et al. Clinical characterization of acute myeloid leukemia

with myelodysplastic-related changes as defined by the 2008 WHO classification system. Blood. 2009;113(9):1906-1908.

Bone Marrow Laboratory Test Specifications

TEST SPECIFICATIONS: BONE MARROW LABORATORY Bone Marrow Aspirate Smears, Bone Marrow Particle Preparation, and

Bone Marrow Biopsy

DELIVER ALL SAMPLES DIRECTLY TO THE FLOW CYTOMETRY LABORATORY CLB

Room 9032 3477 Euler Way

Pittsburgh, PA 15213

Phone: 412-864-6173 Fax: 412-864-6102

BONE MARROW LABORATORY HOURS OF OPERATION Monday through Friday: 8:00am to 5:00pm. The bone marrow specimens can be sent anytime. However they will be processed the following working day if received after hours of operation. The laboratory is also closed on the following holidays: New Years Day, Martin Luther King Day, Memorial Day, July 4

th,

Labor Day, Thanksgiving Day, and Christmas Day. SPECIAL INSTRUCTIONS

Send a completed requisition.

Call the Clinical Flow Cytometry Laboratory (412-864-6173) first before sending, to make prior arrangements about where to deliver.

In packaging bone marrows, please: 1. Tightly close the biopsy container. Keep container upright. 2. MARK THE DATE AND TIME THE BIOPSY WAS PLACED IN THE B-PLUS FIXATIVE – on the

container. 3. Package slides separately from the biopsy specimen (to avoid vapor fixation of the slides).

Use adequate safety measures when transporting specimens. BONE MARROW EXAMINATION TEST DESCRIPTIONS Bone marrow examinations may include aspiration with smears, particle preparations or clot sections and biopsies. Aspirate smears are most useful to examine the cytological detail of the marrow elements and for cytochemical and immunocytochemical stains. The aspirated material may also be used for culture, flow cytometric immunophenotyping, cytogenetic, molecular, and other special studies. The particle preparation represents non-decalcified tissue sections of filtered bone marrow aspirate spicules. This allows for histopathologic analysis of a large volume of marrow with excellent morphology and an intact architecture so features such as cellularity can be easily assessed. It is suitable for a wide range of special stains including immunohistologic stains. Bone marrow core biopsies are decalcified, sectioned, and routinely stained with H&E stain. Biopsy specimens are used to evaluate cellularity, hematopoiesis, non-aspirable lesions to see the topographical relationship of focal lesions to the bony trabeculae, and for evaluation of bone and vessels. BONE MARROW ASPIRATE SMEAR SPECIMEN REQUIREMENTS

10-20 bone marrow slides should be made at the bedside from the first syringe pulled. Label each slide with name, date, and time of collection. The number of slides sent will vary depending on the tests requested. Send the slides in either durable cardboard slide holders or plastic slide holders accompanied by a requisition.

If bilateral (right and left hips) bone marrows are done, then label slides left or right hip.

Send the slides in either durable cardboard slide holders or plastic slide holders. The number of slides sent will vary depending on the test requested.

For a basic bone marrow aspirate interpretation based on Wright-Giemsa stains, send two labeled slides plus a recent CBC/differential result and the corresponding peripheral blood smear.

If cytochemical or iron stains are requested, the following is a list of the minimum required number of unstained slides that should be sent. Send one additional slide for a Wright-Giemsa stain in all cases. In addition, extra unstained slides are useful if any stains need to be repeated.

1 SLIDE:

Iron Stain Naphthyl AS-D Chloroacetate esterase stain (CAE) Myeloperoxidase cytochemical stain (MPO) Sudan Black Stain Periodic Acid Schiff Stain (PAS)

2 SLIDES: Non-specific Alpha Naphthol Acetate Esterase Stain (NSE) Double Esterase Stain (NSE+CAE)

If there are any questions regarding cytochemical stains call the Special Testing Laboratory at (412) 864-6179.

BONE MARROW PARTICLE PREPARATION SPECIMEN REQUIREMENTS

Five milliliters of bone marrow aspirate (preferably from the first or second syringe), placed in a yellow top (ACD) Vacutainer tube.

Store at room temperature.

The material for the particle preparation will be filtered, fixed, and processed by the bone marrow and histology laboratories, at UPMC Oakland.

In addition submit two aspirate smears, the most recent CBC/differential and corresponding peripheral blood smear.

BONE MARROW BIOPSY SPECIMEN REQUIREMENTS

4-6 touch preparations of the biopsy specimen (3 imprints on each slide) made at the bedside. Label each slide with patient's name, date, and time of collection.

Place the biopsy into B-Plus fixative. MARK THE TIME AND DATE THE BIOPSY WAS PLACED IN THE B-PLUS FIXATIVE ON THE CONTAINER. The B-Plus fixed biopsy should be delivered to the laboratory the same day it is done. Prolonged fixation in B-Plus Fixative makes the biopsy difficult to process.

If performing bilateral (right and left hips) biopsies, each biopsy must be placed in SEPARATE B-Plus fixative containers and labeled left or right hip.

In addition submit two aspirate smears, the most recent CBC/differential and corresponding peripheral blood smear.

WARNING: B-Plus fixative contains formaldehyde. Formaldehyde is a carcinogen, irritant, and highly toxic. Avoid contact with eyes, skin, and clothing. Do not inhale.

CONTACTS, DIVISION OF HEMATOPATHOLOGY Steven Swerdlow, M.D. Director, Division of Hematopathology (412) 647-5191 Miroslav Djokic, M.D. Director, Adult Bone Marrow Service (412) 692-2128 Celina Fortunato Lead technologist, Bone Marrow Lab (412) 647-0263 Rev 4/13

Summary of Test Specifications for ancillary laboratories (principally for marrows)

*Flow cytometry (see also detailed test specifications)

-Bone marrow aspirate (2-4 ml) is placed into a heparinized Vacutainer.

Cytogenetics (chromosome analysis)

-Bone marrow aspirate (1 ml) is placed into thawed cytogenetics media. A heparinized (green top) Vacutainer can be used if there is no media available.

*Gene rearrangement (molecular oncology)

-Bone marrow aspirate (2.5 ml) is placed into an EDTA Vacutainer.

*Cultures

-For bacterial cultures fill 3 small isolator tubes (3-cc total) with bone marrow aspirate.

-For viral cultures place 1-2 ml of bone marrow aspirate into a heparinized Vacutainer. (Excluding Parvovirus)

*Parvovirus by PCR

-Place bone marrow aspirate (2.5 ml) into an EDTA Vacutainer.

-This test is sent to Magee Hospital.

*CMV by PCR

-Place bone marrow aspirates (1-5 ml) into ACD Vacutainer.

-Test is performed in virology lab.

Bone Marrow After-Hours Procedures

UPMC Presbyterian Shadyside Special Hematology Policy: BM 3.0 Subject: After Hours and Emergent Bone marrow Collection and Processing Effective date: 1986

POLICY/PRINCIPLE It is the policy of the Special Hematology/Bone marrow room to assure that bone marrow specimens collected after hours or in emergent situations are properly collected and yield the optimal quality and volume to enable the most accurate diagnosis. SCOPE Instructions for collection of bone marrow specimens for specific departments are listed in the Medialab document BM 2.0 entitled Bone Marrow Collection Procedure , for accessioning document Proc 21.0 entitled Bone Marrow Specimen Accessioning and for grossing directions document Proc 31.0 entitled Bone Marrow Grossing and Dictation. RESPONSIBILITY All personnel who assist on bone marrow collections.

PROCESS:

1. The Bone marrow technologist is available Monday through Friday between the hours of 8:00 AM and 4:00 PM. (exclusive of weekends and all UPMC holidays) to provide bedside assistance with bone marrow procedures. At all other times assistance at UPMC PUH campus is not available. For assistance at UPMC Shadyside, call (412) 623-6011. For assistance at UPMC CHP Lawrenceville, call (412) 864-9877. Bone marrow assistance at UPMC Magee Women’s Hospital is provided by the cytogenetic laboratory. For assistance call, (412) 641-5558.

2. On weekends and holidays if an urgent request for bone marrow assistance

arises on UPMC PUH campus, inform hematopathologist on-call/CP resident on-call about the patient so they can inform clinician about alternate testing options available.

3. CHP bone marrow specimens requiring immediate afterhours attention (e.g. acute leukemia), the CHP ATL technologist will triage the sample for ancillary tests, perform a quick stain of 2 aspirate smears, ship 1 stained aspirate slide, 1 peripheral blood smear and current CBC results with the rest of the bone marrow to the CLB Flow Cytometry Laboratory, 9th floor, room 9032 and notify the on- call CLINICAL PATHOLOGY RESIDENT and hematopathologist. The second stained aspirate smear will be placed in a folder in the CHP Heme lab for the Heme/Onc clinician to review.

4. Routine bone marrow specimen processing: Not available after 5:30PM Monday to Friday and Saturday after 12 noon. Bone marrow aspirate and biopsy specimens that cannot be delivered in time to be processed can be kept in the Hematology labs of SHY and CHP hospitals in the room temperature and sent the next morning to the CLB Flow Cytometry processing area.

This procedure is also followed if Monday is a holiday.

Outside bone marrow cases: Monday - Friday evenings all outside bone marrow cases are delivered to the CLB Flow Cytometry specimen processing area room 9032 and processed on the next working day by a specimen processor.

5. EMERGENT bone marrow biopsies on weekends and holidays:

Bone marrow specimens will be accessioned and most biopsies grossed in until 12 noon on Saturdays by the Special Hematology staff.

Note: On Saturdays, Histology needs to receive bone marrow biopsy specimens before 12 noon in order to process it on the overnight processor and be ready the next working day (Monday or Tuesday if Monday is a holiday).

If an EMERGENT specimen is received on Saturday (after 12:00PM), on Sunday or on a UPMC holiday, the on-call hematopathologist must be contacted to decide if the bone marrow biopsy qualifies for the emergent processing.

The EMERGENT bone marrow biopsy will be accessioned and grossed in by the Clinical Pathology resident on-call using the following MediaLab procedures:

- Proc 21.0: Bone Marrow Specimen Accessioning - Proc 31.0: Bone Marrow Grossing and dictation

The CP resident on-call will deliver the grossed in bone marrow biopsy to the Histology lab, CLB 2nd floor room 2018 and place it in the ‘Medspeed blue IN bin’. The bone marrow biopsy will be processed by the Histology evening staff and ready the next working day (Monday or Tuesday if Monday is a holiday).

Note: Please refer to the Medialab policy HIST 113 entitled Weekend and Holiday Procedures for the Histology information.

6. Flow Cytometry:

If specimens cannot be delivered by 5:30 PM Monday through Thursday, leave the specimen at room temperature at the UPMC SHY or CHP Hematology lab. It will be sent to the Flow Cytometry lab the next working day.

If specimens cannot be delivered by 5:30 PM on Friday, or if there is a specimen obtained before noon on Saturday, call the Flow Cytometry lab between 8 AM and 1 PM on Saturday at (412) 864-6173 to inform them that a specimen is being sent to the Flow Cytometry lab. Leave an Audix message if the Flow lab is closed.

Specimens from Saturday afternoon, Sunday, Thanksgiving, Christmas and other holidays after 1 PM, should be held at room temperature and then sent

to the Flow Cytometry lab the following normal working day (Monday or Tuesday if Monday is a holiday).

Only on holidays that fall on Monday: flow technologist is on call between 9-1

PM.

Any holiday that falls on a weekday: flow lab is usually closed. However, flow lab is never closed 2 days in a row. Check with attending if major holiday is on weekend.

In an emergency on all other Monday holidays before 1:00 PM, clinicians are to page the CP resident on-call who will then contact the hematopathologist on-call. All specimens received after 1PM are held until the next morning.

The Flow Cytometry technologist on call is then contacted by the hematopathologist as needed (pager 6331, long range (412)565-9553).

7. Cytogenetics:

Monday through Thursday, specimens that cannot be received by the Cytogenetics lab before 5:30 PM should be stored at room temperature overnight. Specimens are sent to the Cytogenetics lab the next day.

For specimens obtained Fridays that cannot be received by the Cytogenetics lab by 5:30 PM, leave the specimen at room temperature in the Cytogenetics bin in the CLB specimen processing area or SHY/CHP Hematology areas for pick up on Saturday.

Saturday/Sunday/Holiday specimens: Be sure that the specimen gets to the CLB specimen processor. The SHY and CHP specimens will be delivered to the Cytogenetics lab directly from SHY and CHP hematology. The CLB specimen processor or SHY/CHP technologists will contact the Cytogenetics lab by page at (412) 917-9458. Cytogenetic lab personnel arrange for the courier pick up of these specimens. Alternatively, call (412) 641-6688 and follow Audix instructions.

8. Molecular Diagnostic studies:

Specimens should get to the lab by 4 PM if at all possible. If other arrangements need to be made or any questions answered, the attending on-call will be available at pager (412) 433-9591. They may be able to have someone come in on Saturday.

Specimens that have to be held over the weekend or holidays are held as follows:

o DNA testing: Keep the samples at room temperature.

o RNA testing: Refrigerate the samples at 4o C. o DNA and RNA testing: Refrigerate the samples at 4o C. o Tissue samples: Freeze the samples at -20o C.

A molecular specimen drop off bin is located in the CLB-ATL specimen processing area.

9. The Flow Cytometry Lab, processing room is the central receiving area for bone

marrow specimens received from UPMC and non-UPMC affiliated hospitals. The lab is open from 8:00 AM to 6:00 PM, Monday through Friday and from 8:00 AM to 4:30 PM Saturday. During these hours the flow technologists/processors are responsible for triaging the specimens they receive (except as noted in number

5). If they receive a marrow requiring emergency review after 5 p.m. or on the weekend, they will contact hematopathologist/CP resident on-call.

If a routine bone marrow specimen is delivered to the UPMC PUH Gross Room, hold specimen to the next working day and either send with the courier or hand deliver to CLB Flow Cytometry processing area.

Revised 03/2016

Lymph Node Experience

Lymph Node Pathology Experience (~4 weeks) Lymph Node Sign Out

A. “On call” for processing of fresh lymph node biopsies.

NOTE: One of the lymph node assistants are available to help gross from 9-5:30/6 pm. The lymph node assistant pager number is 412-958-7432. They will independently gross most specimens but may require help either over the telephone with images that can be seen using our gross imaging “telepathology” or you may need to help them in person in the CLB (Room 9032). If you get called during these hours, be sure to page the lymph node assistant if they are not already in or on their way to the grossing area in the flow cytometry laboratory (CLB 9032). After 5:30 pm and until 9 pm, the Hematopathology fellow or resident on an extended day shift (see Hematopathology Schedule) can help. On occasion, one of the lymph node assistant should be able to gross in lymph nodes or help out until 6:00 pm.

Become familiar with detailed lymph node protocol, spleen protocol and consult procedures.

B. Sign out of both fresh and consult lymph nodes and related material with staff. Be sure to meet with hematopathologist on lymph node service to review organizational aspects of this rotation. Become familiar with role of the lymph node assistant, use of hematopathology case worksheet, established procedure for organization of sign-out materials, reviewing flow cytometry and guidelines for dictating reports.

C. Review of educational materials.

Checkpath (images, histories and explanations of faculty CME program for Hematopathology)

(PUH G315 and in Dr. Swerdlow’s coordinator’s office). Teaching/conference sets of glass slides of marrows, lymph nodes, etc. (Dr. Swerdlow’s office). Lymph node chapter in Sternberg. Swerdlow, S.H., Campo, E., Harris, N.L., Jaffe, E., Pileri, S.A., Stein, H., Thiele, J., Vardiman, J.

(Eds.): WHO Classification of Tumours Pathology of Haematopoietic and Lymphoid Tumours, IARC, Lyon, 2008.

Ioachim, HL Medeiros, LJ. Ioachim’s Lymph Node Pathology, 4th edition, 2009. Jaffe ES, Harris NL, Vardiman J, Campo E, and Arber D. Hematopathology, 2010 Web-based resources.

D. Review results of ancillary studies procedures performed on lymph nodes you have reviewed

and read addenda that faculty issue.

APPENDIX I -SURGICAL PATHOLOGY MANUAL: LYMPH NODE PROTOCOL

Subject: The protocol is for lymph node or extranodal biopsies with suspected hematopoietic or lymphoid disorders.

1.0 Principle

Diagnostic lymph node biopsies and other biopsies with suspected lymphoproliferative disorders should be handled in a standard fashion to optimize histiologic sections and make appropriate ancillary studies available.

2.0 Specimen

2.1 Criteria:

All tissues where lymphoma is suspected or documented in the patient history as well as all lymph node biopsies in which the only specimen submitted for study is the nodal tissue, and if performed, a frozen section has excluded metastatic carcinoma. Cases where post-transplant lymphoproliferative disorders are suspected are not included unless requested by the Division of Transplant Pathology. Lymph node excisions performed solely as non-lymphoma staging procedures are not included unless gross, touch imprint or frozen section studies suggest a hematopoietic/lymphoid neoplasm. The protocol should be performed under the supervision of a hematopathologist or designate if at all possible.

Emergent lymph nodes on weekends and holidays:

The AP resident should be paged who will determine the most appropriate resident on call to handle the specimen. After hematopathologist’s approval, the resident on call will make the LN specimen Same Day Rush Priority. The on-call resident will contact the histotechnologist on call (pager 12239) and take the LN specimen to the Histology lab located in the CLB room 3018. The Histotechnologist on call will place the LN specimen on the overnight processor so the specimen will be ready the next working day.

2.2 Fixation:

Fresh or saline moistened tissue. RPMI essential media is used to transport tissue. Formalin or any other chemically fixed tissue cannot be processed using this protocol and will be handled according to general cutting manual techniques. Specimens received in formalin in which lymphoma is suspected should have at least one section post-fixed in B+ fixative.

2.3 Sample size:

Any size tissue can be processed.

3.0 Reagents, Supplies and Equipment

3.1 Reagents:

B+ Fixative

100% formalin

10% formalin

OCT

(Warning: Formalin is a suspected carcinogen. HANDLE WITH CAUTION. DO NOT INHALE. See MSDS Binder.)

(Warning: B+ fixative contains zinc chloride and formaldehyde. HANDLE WITH CAUTION. DO NOT INHALE. See MSDS Binder.) 3.2 Supplies:

Lymph Node Gross Dictation Sheet (Appendix E) Log for freezer (Appendix C) Liquid nitrogen

Cytocentrifuge cardboard Slides (Regular and “+” slides) RPMI essential media Beam capsules Marking pens Tissue processing cassettes Personal protective supplies Gloves Apron Shield Plastic freezer box to hold Beam Capsules

Saline solution for Molecular studies Specimen bags Sterile containers Forms for Molecular Diagnostics (Appendix J) Forms for Cytogenetics Lab (Appendix K)

3.3 Equipment:

Liquid Nitrogen tank

-80° degree freezer

Scalpel

Forceps

4.0 Calibration and Standardization Not Applicable 5.0 Quality Control

5.1 All problems noted with specimen processing will be entered under the "Adverse Event" section for each case in CoPath. (See Appendix G.)

6.0 Procedure

6.1 If a frozen section is requested, call the responsible surgical pathologist and resident. The first part of the gross description should be filled in on the template. The specimen should be kept as intact as possible and cut as illustrated and described in sections 6.7-6.10. If the frozen section shows metastatic carcinoma, the case will be handled as per routine, in the surgical pathology division. If

metastatic carcinoma is not identified, continue with protocol. The cassette designation for the resubmitted frozen section should be filled in on the gross description template—(FS).

NOTE : ALL HEMEPATH SPECIMENS ARE GROSSED IN THE FLOW CYTOMETRY LABORATORY – CLB Room 9032

6.2 Place tissue in gauze soaked in RPMI in a sealed container labeled with patient name and surgical number.

6.3 Page the hematopathology LN assistant first. If LN assistant does not answer, page the hematopathology fellow or resident on call for lymph nodes (See schedule). If any problem, call the Hematopathology Division Coordinator at 647-5191 and have her contact the Hematopathology resident or fellow on call. If Coordinator does not answer, call the Hematopathology secretary 412-647-0382 with the same instructions. If the LN assistant and trainee on call or on the LN service cannot be found, page the faculty on the LN service or if necessary the faculty on call.

If no one answers, contact any of the hematopathology fellows or any other hematopathology faculty.

6.4 Specimens that arrive in the evening will be handled by the hematopathology fellow or resident on an extended day shift who will follow this protocol as best they can. Material may be held in RPMI for flow cytometry but this should only be done if there is enough tissue for 2 good histologic sections plus enough for 3 snap frozen pieces. No material will go directly to the molecular laboratory. If the following day is a workday and you are unfamiliar with this protocol, place the entire specimen in RPMI, place in the refrigerator and notify hematopathology the following morning (See 6.3).

Emergent lymph nodes on weekends and holidays: After hematopathologist’s approval, the resident on call, assigned by the Chief resident, will make the LN specimen Same Day Rush Priority . The resident will contact the histotechnologist on call (pager 12239) and take the LN specimen to the Histology lab; CLB-2nd Floor. The Histotechnologist on call will place the LN specimen on the overnight processor so the specimen will be ready the next working day.

In the event of receiving a portion of tissue from a non-lymph node specimen for ancillary studies from an organ specific bench:

a) A section of tissue is taken for Histology on specimens sent to us for ancillary studies. When there is not enough tissue, the specimen will be entirely submitted for flow.

b) A block with a new name will be created in CoPath “HP” for (Hematopathology).

c) A section from the tissue taken by the technologist will be submitted to Histology in the block named “HP”.

d) Comment will be entered in CoPath by the technologist for histology to send the H&E to Hemepath. If it turns out not to be Hemepath’s case, this H&E will be forwarded to the appropriate center of excellence.

e) The Technologist will make sure that block “HP” is assigned to the correct specimen part in CoPath. If 1 cassette is needed from part 2, Example: Part 2, block HP, if more cassessts are needed, Example: Part2, block HP1, HP2, HP3, etc. Gross description must clearly reflect this.

6.5 Inform the lymph node service assistant or resident, fellow or, if necessary, the hematopathologist on lymph node service that tissue has arrived in the Flow Cytometry Laboratory CLB Room 9032.

6.6 Observe tissue grossly and write down brief gross description on template. (Appendix D) Describe size, color, and consistency.

6.7 Cut lymph node perpendicular to the long axis. Keep tissue moist at all times:

6.8 Cut a small paper thin slice, place on a cytocentrifuge preparation cardboard and make 2 fixed imprints (done on regular slides) which can be stained immediately with H&E and 3-5 air dried imprints (done on “+” slides) to be saved at the LN grossing station until the case is completed (for additional special studies, if appropriate). Unused slides are filed in the slide file drawers. The code TP documents the test.

6.8.1 Look at the touch imprint to make a preliminary assessment of the lymph node. If performing flow cytometric studies, check if any special studies should be performed (e.g., if the cells appear blastic, an acute leukemia panel should be run) and about the size of the cells that are of interest (small, large, mixed) and inform the flow technologist. If no one is present in the flow lab write the request on the requisition and place it together with the specimen in the refrigerator located at the flow lab CLB 9th floor- Room 9032 (See 6.3).

6.9 The central portion of the lymph node should be cut into 2-3 mm slices and if >2 cm in maximum dimension, hemisected (sometimes it is easier to initially cut 5-6 mm slices and after brief fixation to slice in half). Include the node capsule in the sections. Be sure to include any focal lesions. No pieces should be larger than 1.5 x 2 cm.

6.9.1 Fix at least one section in 10% neutral buffered formalin. If tissue is very limited, formalin fixation takes precedence over B+ fixation.

6.9.2 Each cassette has a unique designation (ACMB/DNA, BB+, C, etc). Be sure to use the appropriate cassettes. PH White Rule out lymphoma cassettes will be labeled using the cassette engraver with the surgical pathology number and a unique block designation [A(CMB/DNA) OR AFS (for frozen section), BB+, C, etc.] by selecting PH White (R/O Lymphoma). For needle core biopsies or tiny pieces of tissue, specimens should be marked with eosin and wrapped in filter paper and put into mesh cassettes. Note in your gross description if you feel the tissue may not survive processing.

6.10 Use end positions (*) for the following (unless focal lesions are present only in this area or only in the midportion).

* *

6.10.1 Culture, if appropriate, and if the surgeon has failed to do cultures (unless sterile, only AFB and fungal cultures are generally meaningful).

6.10.2 Cell suspension immunophenotypic studies (flow lab 624-3746). Keep ½ to 1 cm3 fresh and moist for this. Place in container with 50 ml RPMI media. Label and place in a biohazard bag with a copy of the requisition with flow panel decided.

6.10.3 Snap freeze tissue 3+ blocks (approximately 7x4x3 mm) in cryovial capsules (2 without OCT and 1 with OCT) labeled with the surgical pathology number in the liquid nitrogen tank in flow lab. If a surgical pathology number is unavailable at the time, print the patient’s full name and date on the tube. Snap capsules onto cryocane, dip into liquid nitrogen tank for a least 60 seconds. These are to be placed in the –80o C freezer (place in current capsule box) located in

the CLB room 9032 lymph node grossing area in the designated box and logged in on the log

sheet located on the freezer.

6.10.4 Submit a 7x7x5-mm piece to the Clinical Molecular Diagnostics Laboratory for possible molecular diagnostic studies. Place tissue in a container with saline labeled with surgical number and place in a self-sealing biohazard bag. Submit an adjacent piece for routine processing labeled CMB/DNA to document the nature of piece sent for molecular studies. Place a copy of the requisition and a filled out Molecular Diagnostics form in the side pouch of the bag. Place a Molecular Diagnostics sticker on specimen bag. During working hours (Monday-Friday 7am-3: 45pm) tube to station #370. After hours place in lymph node fridge next to grossing bench.

6.10.4.1 After hours place specimen in the lymph node refrigerator next to the grossing station on side door and send it the following day.

6.10.6 If there is a high suspicion of lymphoma and enough tissue after all of the above portions are taken, place a 7x7x5 mm (or larger) fresh STERILE piece of tissue in RPMI to send to the Cytogenetic Laboratory for chromosome (karyotype) analysis. Place a Cytogenetics sticker on specimen bag.

6.10.6.1 The specimen can be tubed to station #417 (Magee Womens Automated Testing Laboratory) at any time Monday- Saturday (up until 1:00pm)

6.10.6.2 After 1:00pm on Saturday, place specimen in the lymph node refrigerator next to the grossing station for it to be tubed to station #417 the following Monday by the LN assistant.

6.11 Note:

6.11.1 A well-fixed section is the highest priority although almost no node is too small to preclude snap freezing one piece.

6.11.2 Lymph nodes received in formalin can still be post-fixed in B+

6.12 Once the protocol is completed, the fixed portions are submitted to histology and the completed gross description template dictated.

6.13 Summary of Lymph Node Protocol

6.13.1 Touch Imprints

6.13.1.1 Quick fix in alcohol and stain with H&E for immediate review

6.13.1.2 Air dry, place in box next to the grossing station.

6.13.2 Fresh tissue for special labs

6.13.2.1 Fresh piece in RPMI for flow lab (give to the flow tech)

6.13.2.2 Fresh piece in saline for molecular diagnostics (See 6.13.4.4)

6.13.2.3 Fresh piece in RPMI for Cytogenetics

6.13.2.4 Fresh piece to Microbiology if required.

6.13.3 Snap freeze 2 pieces of fresh tissue in beem capsules and 1 piece in Beem capsule in OCT and store in box in -80 freezer located in the LN grossing area. See protocol for details.

6.13.4 Fixed tissue sections

6.13.4.1 If frozen section was performed, submit FS piece in cassette A in formalin.

6.13.4.2 Cut thin and fix ≥ 1 sections in cassette BB+ after B+ fixative. Put time on jar.

6.13.4.3 Submit one section of tissue in cassette ACMB/DNA fixed in formalin that is adjacent to the molecular diagnostics piece.

6.13.4.4 Submit the remainder of tissue in cassettes C, D, E, etc.

6.13.4.5 Use White colored cassettes to be engraved by selecting PH White (Rule out lymphoma) under ‘Block Detail’ in the Histology section.

6.13.5 Comments

6.13.5.1 If during normal working hours the lymph node assistant/ hematopathology fellow/resident (staff) should be called to perform this protocol.

6.13.5.2 If very little tissue is present, good histologic sections and one snap frozen piece are generally the highest priorities.

6.13.5.3 A gross dictation template should be used.

6.13.6 Diagram of Summary

B+ and formalin fixed sections

Snap freeze 3-5 pieces

Molecular Lab with adjacent piece submitted

in fixative “CMB/DNA Flow Laboratory

If required --Culture

Cytogenetics

Touch Preps

Fix and stain

Air dried & Save 7.0 Calculations

Not Applicable

8.0 Reporting Results / Normal Values

Not Applicable

9.0 Periodic Maintenance

Not Applicable

10.0 Procedural and QA Notes

Not Applicable

11.0 Limitations

Not Applicable

12.0 References

Banks, PM Technical Aspects of Specimen Preparation and Introduction to Special Studies. In: Jaffe, ES Surgical Pathology of the Lymph Nodes and Related Organs. pages 1-22, 1995, W.B. Saunders, Philadelphia.


Revised 7/2004 LF Revised 1/2010 Revised 3/2010 CF Revised 10/2013 LF

How to handle very small specimens being submitted for histology*

1. Specimens should be marked with eosin and wrapped in filter paper and put into mesh cassettes. Note in your gross description if you feel the tissue may not survive processing.

2. The histology lab will contact the responsible house-staff officer and faculty member immediately if there is a failure to identify tissue in a cassette.

RECUTS OF SMALL PIECES OF TISSUE

Suggestions from Dr. Yousem when you are asking for recuts of very small pieces of tissue. It would be very worthwhile to alert Histology that the fragments of tissue are small and care must be taken. Instructions in the stain comment fields are helpful. 1. Tell the lab to "take sections right off the top", "do not face the block"- this alerts them not to aggressively

"face" the block 2. Tell the lab to take "serial sections"-- this way they do not lose sections between the ones obtained for your

stain requests 3. Ask for unstained slides in addition to the required ones-- this allows you to have extras should the stain

not work or tissue fall off the slide 4. If it is a very tough case, ask that an experienced technician handle the case- make this request in the

comment or call the lab 5. Cell blocks in cytology should always contain this type of request, in my opinion.

Pictorial Version of Lymph Node Protocol (Double click on the link below for the PowerPoint Presentation)

Z:\Linda Koerbel\Fellow LN grossing presentation\Grossing Fresh Lymph Nodes - LF SHS revision 12 09 updated 02-16-2012.ppt

../Linda%20Koerbel/Fellow%20LN%20grossing%20presentation/Grossing%20Fresh%20Lymph%20Nodes%20-%20LF%20SHS%20revision%2012%2009%20updated%202-16-2012.ppt

../Linda%20Koerbel/Fellow%20LN%20grossing%20presentation/Grossing%20Fresh%20Lymph%20Nodes%20-%20LF%20SHS%20revision%2012%2009%20updated%202-16-2012.ppt

Submitting Histology After Grossing When we receive fresh tissue (in saline or RPMI): Submit the cassettes in formalin filled container appropriately labeled “HISTOLOGY LAB” and they can either be tubed to station #320 (Histology lab) or if after hours leave on LN grossing bench to be sent the following day.

NOTE- PLEASE USE YOUR JUDGEMENT

Surgical Pathology Manual: Spleen Protocol

PROCEDURE:

1. Measure the spleen in three dimensions and weigh. 2. Section the spleen transversely at .5 to 1.0-cm intervals. *Photograph any lacerations and/or

surgical tears before transverse sectioning. To take a picture with Nikon digital grossing camera, make sure all power is turned on as follows: turn on power switch on box next to the PC, turn on power button on box at camera, and turn on power switches for both lights. ’Place specimen on camera base on table. In Copath under PHS case no. using Accession Entry Edit or Image entry edit, click on Image gallery, then click “Import from TWAIN”, and then click on “C” to capture the image.

3. The lymph node protocol for handling lymphomas should be followed in cases of suspected lymphoma (staging, etc.) and other hematopoietic disorders.

4. Any hilar nodes or accessory spleen should be submitted separately. 5. Photograph one section of spleen.

DESCRIPTION:

1. Weight and dimensions. 2. Hilum: nature of vessels, presence of lymph nodes or accessory spleen. 3. Capsule: color, thickness, focal changes, adhesions, lacerations (location, length and depth). 4. Cut surfaces: color, consistency, malpighian corpuscles (size, color conspicuous), fibrous

trabeculae, nodules or masses, diffuse infiltration, red or white pulp disease.

SECTIONS:

1. If no gross abnormality is seen, and the spleen is taken out as an incidental splenectomy, submit two to three random sections.

2. If the spleen is grossly lacerated, submit two to three random sections including the area of laceration.

3. If it is a leukemia or lymphoma case, submit a minimum of five sections (B+ and formalin fixed), including any distinct nodules. Several nodules should be submitted in cases of focal disease. At least one section should include the capsule. Sections should be thin and no larger than 1.5 x 2.0 cm.

ANCILLARY STUDIES:

1. Make certain that if a hematopoietic/lymphoid neoplasm is suspected, tissue is processed for all the

potential ancillary studies described for lymph node biopsies. Revised 10/2013

LYMPH NODE GROSS DICTATION –TEMPLATE

Dictation phone # 802-6706 Work type #9004 For multiple parts use other side>>>

CASE# PHS___: __________________

NAME: ______________________________

MEDICAL RECORD #___________________

PLEASE DICTATE CLINICAL HISTORY AS STATED ON REQUISITION

The specimen is received [fresh in RPMI or formalin] labeled with the patient’s name, initials ___, MRN, and [specimen site] ”___________________” It consists of______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Air dried touch preparations are performed, material is snap frozen (__ blocks), and sent for cell suspension immunophenotypic studies (flow cytometry). A portion is sent to the molecular diagnostics laboratory with an adjacent section submitted in cassette A (CMB/DNA). Additional material is sent for cytogenetic studies. The [remainder or representative sections] of the [site location] is (are) submitted in cassettes BB+ after B+ fixation and in blocks C - ______ after formalin fixation.

Note: Do not use the B+ fixation if you only are submitting one block, formalin only.

(NOTE: IF a frozen section was submitted by another bench, submit in cassette AFS.) Make sure you order ‘FRZ1’ in Stain Process for every frozen section block submitted

Checklist for specimens: *Make sure all containers, slides, and frozen capsules are labeled with the case # and patient’s name*

__Touch preps ---2 stained (H&E) on regular slides to evaluate what type of flow panel to

order

__3 air dried slides on PLUS charge slides for possible Cytogenetic FISH studies

___ Cassettes are ordered under ‘Block

Detail’ , then select PH White (R/O Lymphoma) under engraver type

__Put the Date and Time on the formalin and B+ fixative container __Snap frozen- 2 capsules without OCT compound (only if enough tissue available) , then 1 capsule with OCT

__Flow cytometry- container with RPMI (found in refrigerator) w/ copy of requistion

NOTE- On call fellows/ residents: please put

flow specimen on top shelf of flow fridge (located centrally in lab next to biochemical hood) and put requisition with flow decision

on staining bench.

_Molecular Diagnostics- container with Saline (found at grossing bench) fill out MDX form and tube to station # 370 Hours Mon-Fri 7am-345pm. After hours, put in LN fridge

to be sent following day.

__Cytogenetics- container with RPMI, fill out form---- tube to station #417 anytime (but

after 1p Saturday-put in LN fridge).

Write on sides of blocks: B+ fix on B+ fixed blocks

Protocol to order in histology- ‘Rolym’ (select the ‘load’ box then ‘run protocol’ button)

Policy for solid tissue specimens sent to rule out lymphoma that overlaps with other Centers of Excellence In certain circumstances, specimens that fall into a non-Hematopathology Center of Excellence will either be designated “rule out lymphoma” by the surgeon or have a potential lymphoma discovered either when a frozen section is performed or when a fresh specimen is examined grossly. For example, a salivary gland may be removed and a frozen section of a mass demonstrate a dense lymphoid proliferation without evidence of a carcinoma. If an intraoperative consultation is requested, the specimen should be handled by the surgical pathology

resident/fellow/pathologist on call at the hospital where the specimen has been removed. In all cases, following completion of any required intraoperative consultation, both the

resident/fellow/pathologist on service for the Center of Excellence and the Hematopathology “lymph node” resident/fellow/pathologist should be notified that the specimen is in the gross room. A joint decision should be made at that time by both parties as to whom the primary pathologist should be based on factors such as the likelihood of other pathology being present or any concern that a hematopathology protocol would compromise any aspect of the pathologic examination.

In cases where the Center of Excellence is not located at UPMC-Presbyterian Hospital, the decision as to

whether the specimen should be handled in whole or in part by the Division of Hematopathology should be made at the originating hospital. This should either be done by members of the Center of Excellence (for example, if there is a GU specimen at UPMC-Shadyside) or after telephone agreement with the appropriate AP-related COE pathologist. This will eliminate the possibility of specimens being sent first to one hospital and then another. The resident/fellow/faculty on lymph node service should be consulted if questions occur.

The Hematopathology “lymph node” resident/fellow/pathologist will be prepared to accept the responsibility for

processing the entire specimen, for taking a portion of the specimen for a hematopathology workup with the remainder of the specimen grossed in by an anatomic pathology bench or functioning solely as a consultant if special procedures are deemed unnecessary (for example, if suspicion for a lymphoma is low and the tissue sample is very limited).

In cases where the initial triaging to either Hematopathology or one of the AP benches seems inappropriate

after sections are reviewed or ancillary studies become available, if agreeable to all parties, the primary pathologist will be switched to the pathologist on the more appropriate service. This may involve a Center of Excellence pathologist signing out a case not accessioned at their Center of Excellence, and ordering stains that need to be sent by inter-hospital courier.

This model should be applied to all other Centers of Excellence where faculty, fellows or residents should act

to facilitate processing.

Instructions for Fresh Tissue Biopsies Received from Outside Institutions

[Revised 10/2013]

Sometimes tissue specimens from outside institutions are sent to our Flow Cytometry Laboratory for cell suspension immunophenotypic studies or complete workup. In these cases, as long as sufficient tissue is available, we try to do a complete lymph node protocol on them, except that tissue is not sent to the molecular diagnostics or cytogenetics laboratory (except for cases from UPMC-Shadyside, Magee Women’s or other complete case workups that also get material sent for DNA extraction and, if appropriate, for cytogenetic studies). One must remember that if the tissue has been sent here for flow cytometric studies, sufficient tissue must be retained specifically for making a cell suspension. If the tissue submitted is very small, at a minimum, a touch imprint should be performed, and if possible, a small portion snap frozen. On cytologic specimens, if material has been retained at the referring institution, do NOT do touch preps unless there is a lot of material (several good cores) and send the entire specimen to the flow cytometry laboratory. Run the lymphoma protocol in CoPath but be sure to delete all the items that do not apply. You don’t need a CMB/DNA block unless molecular is sent. If there are any questions on a given case, please contact the pathologist covering lymph node biopsies.

Cases from CHP where we are not the primary pathologists traditionally are not sectioned (CHP sections are reviewed prior to sign-out). Cases from other divisions for flow cytometry may have a section taken if there is sufficient tissue and if acceptable to the division (to better know what we are actually doing the flow cytometry on).

All fresh tissue cases from UPMC-Shadyside will arrive in the Flow Cytometry lab and accessioned as UPMC- Presbyterian cases. All other cases from UPMC hospitals (and rare non-UPMC hospitals) should be accessioned as UP consults UNLESS we have the entire specimen (with or without a frozen section). If we have the entire specimen it should be accessioned as a UPMC- Presbyterian case.

Fresh Case Lymph Nodes and Other Solid Tissues Sent to UPMC-Presbyterian for Flow Cytometric Studies with a non-hematopathology Primary Pathologist [Revised 10/2013] All non-PB, non-BM, non-fluid outside cases sent to the Division of Hematopathology for flow cytometry, that are accessioned with a number that is solely being handled by the Division of Hematopathology, need not only to have the flow cytometry signed out, but a complete report in the usual format. That report should include the following components:

A History which is amplified from information that is entered when the case is accessioned and should at least include the information on the requisition. It should also state: “Case received for flow cytometric consultation.”

A Diagnosis - The diagnosis in cases that do not have a definitive malignant diagnosis can be "Flow cytometric immunophenotypic studies are non-diagnostic (see comment)”. Other cases may get a somewhat more definitive diagnosis, but, unless there is an actual disagreement, the diagnosis should be consistent with what the primary pathologist is calling the case. Hence, the original pathologist on almost all of these cases should be called. The diagnosis rendered can be a bit more vague than usual, for example, a follicular lymphoma may be diagnosed without giving the grade.

A Comment - A comment that reiterates the diagnosis and states that the results must be correlated with the material processed at the institution of origin should be included. It may refer to the morphologic findings in the tissue processed or in the cytospin.

A Microscopic Description - The description can be of the morphologic findings in the tissue that is processed or based on the cytospin, if there is nothing else. Or it can state that nothing was processed for morphological studies.

A Billing code – If only H & E’s and flow are done, BC06. If additional workup or complete consultation is performed after discussion with the referring pathologist, BC03, BC04, or BC5 (See “Copath and dictation pointers” .for complete list of billing codes (BC))

In addition, it must be ascertained whether or not the primary pathologist is sending more material on the case BEFORE the rest of the report is signed out. In general, some institutions do and some do not typically send additional material. This should be indicated on the requisition but it is not always clear and not always consistent. On these "BC06" cases (BC14 for the VA), permission must be obtained to order immunostains, FISH, molecular diagnostics, etc. If a full consult is requested on the requisition, IHC may be ordered. The primary pathologist should be asked about doing FISH studies and molecular diagnostics, although if the case is from a UPMC institution it should be acceptable. If a case is not from a UPMC institution, it is critical to obtain permission to order anything other than the H&Es. If you do IHC and flow was done, be sure to put in one of the Flow/IHC comments. These cases also should have a synoptic if they are lymphomas.

Helpful Hints for Handling Consult Blocks

Ordering H&E slides on Consult Cases

With consult cases you must order the H&E as a recut (RHHE) because the only requests that come on the Histology Special Request Log are special stains, Ipex, Hblanks, Iblanks and recuts. The slides that come with the consult case are the original H&E. We cut from the blocks that are sent, therefore it is a true recut.

When consult blocks are sent for special stains/immunos enter them in Client Server as follows: -Under Stain/Process Edit/Entry:

-Select the Part that corresponds to Consult Block/s NOT Consult Slide/s -Select Add Block and enter the block designation as the A, B, C – under block detail go the other block number and put outside case #.

-Hint #1: An initial H&E is ordered automatically; however, it does not end up on the HISTO worklog for some reason, so will never ever get it. You must re-order it as a recut (RHHE) to actually get a slide. -Hint #2: When you Add Stain/Process to a designated block, be careful to select the correct block when ordering stains.

-Sometimes you get blank slides instead of a block; check to see what Part they are accessioned and enter a designation just like a block, as above.

Sending Outside Blocks to Histology

All outside blocks are to be sent in yellow envelopes to Histology via the tube station # 320 with the PUH case

number, patient’s name, Pathologist’s name, and Resident’s or Fellow’s name written with a sharpie pen on

the envelope.

RULES FOR HISTOLOGY

All exceptions must be approved by Dr. Yousem & Dr. Dhir

WHEN ACCESSIONING: Pathology staff must be entered in the following order; Pathologist. (P) Fellow or Chief Resident. (R) If there is no Fellow or Chief Resident on the case enter “none”. If there is no resident, this field can be left blank.

Initial H&E slides will be delivered to the listed pathologist in “reverse rank” order: 1) Resident, 2) Fellow/Chief, 3) Faculty. New Bench Designations and Color Scheme; Please make sure the proper color cassette is used for appropriate handling of specimen.

Hemepath – WHITE R/O Lymphoma Rush Biopsies (PUH/SYS) - PEACH Rush Neuropath (PUH) - GRAY

Cytology (PUH/SYS) - GREEN

ENT Routine (PUH) - PINK

GI Routine (PUH) - YELLOW

Muscle/Nerve Routine (PUH) - ORANGE

Neuropath Routine (PUH) - BLUE

Thoracic Routine (PUH) - TAN

Transplant Routine (PUH) - PURPLE

Autopsy (PUH) - WHITE

Autopsy Neuropath (PUH) - WHITE

Derm Rush (SYS) - GRAY GU (SYS) - WHITE Prostate Routine (SYS) - PINK Skins Rush (SYS) - BLUE Bone/Soft Tissue (SYS) - GREEN

STAT cut off times: The cut off time for receiving stats in the histology lab is 11: 00AM. No exceptions, unless approved by Dr. Yousem and Dr. Dhir. When accessioning Children’s Hospital bone marrows; they must be accessioned under pediatric bone marrows, or they will be sent to the Hemepath lab, along with the other bone marrows. There will be no exceptions.

WHEN ORDERING: RE-CUTS – Must be ordered under RHHE, and the correct number in the count field. If levels are needed, this must be entered in the stain comment field when ordering the re-cuts. The cut off time for ordering re-cuts is 1:00PM to be delivered same day by the 5:30 pm courier run. Anything after 1:00PM that day will be cut and sent the following morning by the 8:30 am courier run. There will be no exceptions unless approved by Dr. Yousem & Dr. Dhir.

SPECIAL STAINS – Must be ordered with the correct special stain code so there is no delay. Please remember and take into consideration that some special stains take 2 or 3 DAYS to complete. The cut off time for ordering Histo stains is 10:00AM and will be delivered on the 2:30PM courier run that day. Anything ordered after 10:00AM will be stained the following day and delivered on the 8:30 AM courier run the following day. The only special stains performed on weekends are the Stat Grocott, AFB, and Gram. There will be no exceptions unless approved by Dr. Yousem or Dr. Dhir.

IMMUNOPEROXIDASE ANTIBODIES – Must be ordered with the correct antibody code so there is no delay. Most Immunoperoxidase antibodies done in the clinical lab have the prefix A; please make sure the correct antibody is ordered. Stains ordered before 10:00AM should come out the same day. Stains ordered after 10:00AM should come out by the 8:30am courier the following day. When ordering special stains, immunos, etc. on blocks that are at Shadyside, order under Shadyside and put a comment in the stain comment field saying where you want the slides sent.

REPROCESSING TISSUE:

Histology technicians are no longer permitted to decide if a tissue needs reprocessing. The pathologist reading the case can only make that decision. Histology must send out a suboptimal slide, which will be highlighted in green. The pathologist needs to determine if the tissue needs reprocessing. The pathologist must call Histology and give permission to reprocess. A better H&E will be sent the following morning.

ORDERING BLANKS FOR INSITU: If the blanks are ordered before 11:00 AM will be sent to ISH on the 11:30AM courier run. Anything ordered after 11:00AM will be delivered to the ISH lab on the 9:30AM courier run.

WHEN HISTOLOGY SENDS OUT SLIDES: All lymph node and all bone marrow slides will be sent to the Hemepath lab. All Transplant H&E slides will be sent to the case pathologist. All Neuropath H&E slides, including autopsies, will be sent to the case pathologist.

All Transplant TB slides ordered will go to the case pathologist. All non-transplant TB slides will go to the resident on the case entered in the comment field. All EM kidney biopsy slides will be sent to the case pathologist. E slides will go to Cytology. All recuts, special stains, and immunoperoxidase stains will be sent to the hospital as specified in the stain comment field when ordered.

All dental slides will go to the Dental department.

All recuts, special stains, and immunoperoxidase stains will be sent to the doctor ordering them. The doctors must enter in the stain comment field when ordering, the hospital where that doctor will be located to receive their slides. Comments override everything: All slides will be sent to the doctor and hospital specified in the stain comment field. For all blocks that need corrections, the appropriate department or person will be notified and they must come to the Histology lab and make the corrections. Histology will no longer be responsible for making changes to the cassettes. In addition, a specimen misidentification form must be filled out in histology. Revised 10/2013

GENERAL FORMATTING REQUIREMENTS

FONT TYPE AND SIZE:

All reports are typed in Arial font, size 9.

GROSS DESCRIPTION

The gross description is typed in sentence style, beginning at the left margin, in paragraph format.

The patient’s initials are typed in all CAPS (i.e. The specimen is received in formalin labeled with the patient’s name and initials, MSP.)

The label of the specimen is typed within quotation marks (i.e. The specimen is labeled “right upper lobe lung” and consists….).

When multiple specimen parts are received a new paragraph is started for each part. (i.e. Part 1, Part 2, etc.), using Arabic numerals.

When multiple specimen parts are received each part’s gross description must include the patient's initials. (i.e. Part 1 is received labeled with the patient’s name and initials, MSP….. Part 2 is received labeled with the patient’s name and initials, MSP.)

For gross specimens with a cassette listing, a period follows the last submitted description only (see example below).

EXAMPLE: Gross description for a one-part specimen Gross Description The specimen is received in formalin labeled with the patient’s name, initials MSP and “rectal biopsy”. The specimen consists of an un-oriented, irregular, soft, tan, tissue fragment measuring 0.2 x 0.1 x 0.1 cm. The specimen is entirely submitted in a cassette labeled A. VGD/vat

EXAMPLE: Gross description for multiple-part specimens Gross Description The specimen is received in formalin in two parts. Part 1 is labeled with the patient's name, initials MSP and “rectal biopsy”. It consists of an unoriented, irregular, soft, tan, tissue fragment measuring 0.2 x 0.1 x 0.1 cm. The specimen is entirely submitted in a cassette labeled 1A. Part 2 is labeled with the patient's name, initials MSP and “antrum”. It consists of an unoriented, irregular, soft, tan, tissue fragment measuring 0.2 x 0.1 x 0.1 cm. The specimen is entirely submitted in a cassette labeled 2A. VGD/vat EXAMPLE: Gross description with cassette listing Note: When a specimen part is submitted in several blocks, these are indicated by a cassette listing at the end of the gross description for that part. It is typed flush with the left margin (in the following order: part number, letter designation, a space, a dash, a space, description of tissue in block). A period follows the last submitted description only. The cassette listing is formatted as follows: The specimen is submitted as follows: 1A – right upper lobe lung 1B – nodule 20 cm from resection margin 1C – stapled resection margin 1D – lung parenchyma 1E – remainder of tissue Gross Description

The specimen is received in buffered formalin labeled with the patient’s name, initials MSP and “skin biopsy”. The specimen consists of an un-oriented, irregular soft tan tissue fragment measuring 0.2 x 0.1 x 0.1 cm. The following sections are submitted: 1A – tips 1B – ends VGD/vat EXAMPLE: Gross description for bone marrow biopsy Gross Description Received are an aspirate (part 1), biopsy, flow cytometry, cytogenetics and VNTR. Part 2, bone marrow biopsy, is received in B5 fixative, labeled with the patient's name (MSP) and site. It consists of a single core of tan, cancellous bone measuring 0.8 x 0.2 cm. The specimen is totally submitted to histology for decalcification in block A. VGD/vat EXAMPLE: Consult material description (congross or cons) (may include a gross description) Consult Material Description Received for consultation from John Doe, M.D., are eleven (11) consult slides and nine (9) consult slides labeled S05-192; one (1) consult slide labeled S05-3303 and one (1) consult slide labeled S05-6039 from Memorial Hospital, Pathology Department, 9888 Generic Avenue, Big City, PA 12345, along with an accompanying letter, surgical and cytopathology reports. VGD/vat EXAMPLE: Bone marrow biopsy clinical history (preop) Clinical History The patient is a 36-year-old male with a history of acute myelogenous leukemia, diagnosed in 04/2003 (PHB03-123456). A bone marrow performed on 02/200 (PHB05-111111) demonstrated 10% blasts. He is currently day 33 status post allogeneic peripheral blood stem cell transplant. The bone marrow is for evaluation of engraftment. Medications: Cycloporin, Diflucan, Acyclovir, Synthroid, Protonix and Magnesium. VGD/vat EXAMPLE: Consultation case, one accession number (y and preop) Clinical History The patient is a 70-year-old male. OSS S05-192, 1/7/2005, MEMORIAL HOSPITAL PRE-OP DIAGNOSIS: None given. POST-OP DIAGNOSIS: None given. PROCEDURE: Fine Needle Aspiration right neck. VGD/vat EXAMPLE: Consultation case, multiple accession numbers (y and preop) Clinical History The patient is a 70-year-old male. OSS-S05-3303, 04/14/2005, MEMORIAL HOSPITAL PRE-OP DIAGNOSIS: Left vocal cord lesion. POST-OP DIAGNOSIS: None given. PROCEDURE: Left vocal cord stripping. OSS-05-6039, 07/07/2005, MEMORIAL HOSPITAL PRE-OP DIAGNOSIS: None given. POST-OP DIAGNOSIS: None given. PROCEDURE: Left vocal cord biopsy. VGD/vat

EXAMPLE: All other surgical clinical histories (preop) Clinical History Abdominal pain. PRE-OP DIAGNOSIS: Abdominal pain. POST-OP DIAGNOSIS: Same. PROCEDURE: Rectal biopsy. VGD/vat GROSS ONLY SPECIMEN REPORTS

The clinical history and gross description are typed as described above in the gross description explanation.

In the microscopic description field type: “No sections are submitted” or “None”.

In the final diagnosis field type (in all CAPS): The specimen line, return and type the dictated final diagnosis followed by the phrase, “gross diagnosis only; see comment” within parenthesis in lower case letters (see example below).

In the diagnosis comment field type the quick text code, gross and click on the running man icon to insert the standard quick text template regarding gross only specimens and further testing. Go to the pound (#) sign using the keystroke combination [ALT+F] and type in the specimen designation.

INTRAOPERATIVE CONSULTATION

The intraoperative consultation text field is typed in ALL CAPS (similar to the final diagnosis section). The only exceptions are: 1) the type of intraoperative consultation is typed in parentheses in lowercase letters (for example: frozen section, gross diagnosis/examination only, touch prep) and 2) the names of intraoperative staff member(s) performing the intraoperative consultation are entered within parentheses at the end of the last line of the intraoperative consultation before the period (first initial of first name in caps and full last name with initial caps and lowercase letters - in the following order: staff pathologist/fellow/resident/PA including the title, M.D. when applicable) (see examples below).

EXAMPLE: Single-part intraoperative consultation Intraoperative Consultation FS: LUNG, LEFT UPPER LOBE, LOBECTOMY (frozen section) – EXAMPLE: Intraoperative consultation with single-line diagnosis Intraoperative Consultation FS: LUNG, LEFT UPPER LOBE, LOBECTOMY (frozen section) –

A. BENIGN (T. Pathologist, M.D). EXAMPLE: Intraoperative consultation with multiple diagnoses Intraoperative Consultation FS: LUNG, LEFT UPPER LOBE, LOBECTOMY (frozen section) –

A. BENIGN. B. NO TUMOR SEEN (T. Pathologist, M.D. /C. Resident, M.D./A. Pa).

VGD/vat

EXAMPLE: Intraoperative consultation for multiple parts with multiple diagnoses Intraoperative Consultation 1AFS: LUNG, LEFT UPPER LOBE, LOBECTOMY (frozen section) –

A. MALIGNANT. B. SMALL CELL CARCINOMA (T. Pathologist, M.D).

2ATP: LUNG, LEFT MIDDLE LOBE, LOBECTOMY (touch prep) –

A. MALIGNANT (T. Pathologist, M.D.). 3AGD: LUNG, LEFT MIDDLE LOBE, LOBECTOMY (gross diagnosis) –

A. BENIGN (T. Pathologist, M.D.). VGD/vat EXAMPLE: Intraoperative consultation for one part with multiple frozen sections/touch preps performed on different blocks Intraoperative Consultation 1AFS: SUPRAGLOTTIC MASS, LEFT, LATERAL, MEDIAL AND DEEP MARGINS (frozen section) –

A. MALIGNANT. B. SQUAMOUS CELL CARCINOMA. C. TUMOR PRESENT AT LATERAL MARGIN. MEDIAL AND DEEP MARGINS FREE OF TUMOR (T.

Pathologist, M.D./C. Resident, M.D.). 1BFS: SUPRAGLOTTIC MASS, LEFT, INFERIOR SHAVE MARGIN (frozen section) –

A. MALIGNANT. B. SQUAMOUS CELL CARCINOMA. C. TUMOR PRESENT AT THE MARGIN (T. Pathologist, M.D./C. Resident, M.D.).

1CFS: SUPRAGLOTTIC MASS, ANTERIOR SHAVE MARGIN (frozen section) –

A. MALIGNANT. B. SQUAMOUS CELL CARCINOMA. C. TUMOR EXTENDS VERY CLOSE IF NOT TO THE CAUTERIZED MARGIN (T. Pathologist,

M.D./C. Resident, M.D.). VGD/vat

FINAL DIAGNOSIS

The Final Diagnosis is typed in ALL CAPS and bold type. The exception: Any text placed within parentheses that is non-diagnostic {i.e. (see comment)} is in lowercase bold type.

The specimen line identifies the specimen, identifies the location of the specimen, and indicates the procedure performed to remove the specimen and is aligned with the left margin. Following the type of excision, type a space, a dash and then return.

Each diagnosis ends in a period.

A single diagnosis is aligned flush with the left margin and not indented.

For multiple diagnoses, each diagnosis is given a letter designation (A, B, C, etc.).

For multiple parts with one or more diagnoses, each part is labeled as PART # and followed by a colon mark and a single space and the specimen line (i.e. PART 1: LUNG…). Each diagnosis is given a letter designation (A, B, C, etc.), with the exception of a diagnosis with only one line. The letter designation is aligned with the beginning of the specimen header in a hanging indent, (created using the keystroke combination [CTRL+M]), followed by a period and a space, and then the diagnosis. Note: When the hanging indent is created, hitting return at the end of the line A diagnosis will create the appropriate indent for the remaining diagnosis lines.

A blank line is inserted between parts.

For consult diagnoses, place the outside slide number and the accession date of the outside slide number in parenthesis next to the diagnosis specimen line.

Expand abbreviations in the final diagnosis field. Example: If the dictator says CIN 1 type CERVICAL INTRAEPITHELIAL NEOPLASIA 1 (CIN 1).

EXAMPLE: Final diagnosis heading - specimen part type, location of specimen, procedure performed

Final Diagnosis LUNG, LEFT UPPER LOBE, LOBECTOMY –

EXAMPLE: Final diagnosis for one part with one diagnostic line

Final Diagnosis

LUNG, LEFT UPPER LOBE, LOBECTOMY – BENIGN. VGD/vat

EXAMPLE: One part, multiple diagnosis lines

Final Diagnosis

SOFT TISSUE KNEE MASS, RIGHT, EXCISION –

A. SKIN AND SUBCUTANEOUS TISSUE WITH FIBROUS-WALLED CYST WITH FOCAL RUPTURE, B. SYNOVIAL CELL PROLIFERATION AND RARE NON-VIABLE BONY SPICULES OF

GANGLION/SYNOVIAL CYST, 11.5 X 3.8 CM (see comment). C. NEGATIVE FOR MALIGNANCY. VGD/vat EXAMPLE: Multiple parts, one or more diagnosis lines

Final Diagnosis

PART 1: GALLBLADDER, CHOLECYSTECTOMY –

CHOLELITHIASIS AND MILD CHRONIC CHOLECYSTITIS. PART 2: LIVER, RANDOM NEEDLE BIOPSY –

A. NON-CIRRHOTIC LIVER TISSUE WITH MICROVESICULAR AND MACROVESICULAR STEATOSIS INVOLVING 30% OF THE HEPATOCYTES.

B. MILD NONSPECIFIC PORTAL CHRONIC INFLAMMATION (see microscopic description).

VGD/vat

EXAMPLE: Bone marrow biopsy final

Final Diagnosis PART 1: PERIPHERAL BLOOD –

WITHIN NORMAL LIMITS. PARTS 2 AND 3: BONE MARROW, BIOPSY AND ASPIRATE –

TRILINEAGE HEMATOPOIESIS WITH FOCI OF LYMPHOCYTOSIS INCLUDING LYMPHOID AGGREGATES (see comment).

VGD/vat

EXAMPLE: Consultation diagnosis, one part, one accession number

Final Diagnosis RIGHT AND LEFT OVARY, BILATERAL SALPINGO-OOPHORECTOMY (OSS S05-6612, 06/14/05) –

A. POORLY-DIFFERENTIATED INTRACYSTIC CARCINOMA WITH FEATURES OF SEROUS AND ENDOMETRIOID CARCINOMA.

B. ADENOCARCINOMA APPEARS TO BE INTRACYSTIC WITHOUT EVIDENCE OF OVARIAN SURFACE INVOLVEMENT ON PROVIDED SLIDES.

C. LYMPHOVASCULAR INVASION IS NOT IDENTIFIED. D. LEFT FALLOPIAN TUBE, HISTOLOGICALLY UNREMARKABLE. E. RIGHT OVARY AND RIGHT FALLOPIAN TUBE WITH PHYSIOLOGIC CHANGES. F. DEFINITE ENDOMETRIOSIS IS NOT IDENTIFIED.

VGD/vat

EXAMPLE: Consultation diagnosis, multiple parts one accession number

Final Diagnosis PART 1: ENDOCERVIX, CURETTINGS (OSS S05-1191, 07/07/05) –

ECTOCERVICAL AND ENDOCERVICAL TISSUE FRAGMENTS WITH NO SIGNIFICANT PATHOLOGIC ABNORMALITY.

PART 2: ENDOMETRIAL CURETTINGS (OSS S05-1191, 07/07/05) –

ATYPICAL COMPLEX HYPERPLASIA IN A BACKGROUND OF SECRETORY PATTERN ENDOMETRIUM WITH TUBAL AND CLEAR CELL METAPLASIA.

VAT/vat EXAMPLE: Consultation diagnosis, multiple parts, multiple accession numbers

Final Diagnosis PART 1: FINE NEEDLE ASPIRATION OF RIGHT NECK (OSS S05-192, 01/07/05) –

A. SATISFACTORY FOR INTERPRETATION. B. NEGATIVE FOR MALIGNANT CELLS. C. FRAGMENTS OF FIBROADIPOSE TISSUE.

PART 2: VOCAL CORD, LEFT, STRIPPING (OSS S05-3303, 04/14/05) –

KERATOSIS WITH MILD DYSPLASIA. PART 3: VOCAL CORD, LEFT, BIOPSY (OSS S05-6039, 07/07/05) –

HYPERPLASTIC, CHRONICALLY INFLAMED SQUAMOUS MUCOSA. VGD/vat DIAGNOSIS COMMENT

The diagnosis comment field is typed in sentence style in bold type, aligned with the left margin, in paragraph format and may contain quick text or free text transcription.

EXAMPLE: Diagnostic comment

Diagnosis Comment

The histologic features seen in this material are consistent with quiescent ulcerative colitis. No dysplasia is seen.

VGD/vat

CLINICAL HISTORY

In the clinical history field, standard quick text templates are used. Type the quick text preop for bone marrows, consultations and all other surgical cases) and click on the running man icon to insert the standard quick text template for the patient's clinical history. Go to the pound (#) signs using the keystroke combination [ALT+F] and type in the dictated information.

The clinical history is typed sentence style (initial uppercase, remainder lowercase; see examples below).

The patient’s age is typed with hyphens (i.e. The patient is a 24-year-old female).

The first word in the pre-op, post-op and procedure are capitalized and each line ends with a period (see examples below).

Consultation cases include the outside slide number (OSS), outside slide accession date and the name of the hospital requesting the consult between the clinical history line and the preoperative diagnosis line in all capital letters and in bold typeface.

SYNOPTICS

A synoptic should be added to all bone marrow and solid tissue reports when a hematopathologic/lymphoid neoplasm is being diagnosed. Currently on the bone marrows, these are being added on first-time diagnoses only, although they do not need to be limited to those cases.

Instructions for the use of synoptics are available online. The CoPath user guide is posted on the CoPathPlus website http://copath.upmc.com under the link for CoPathPlus Training Resources. The Synoptic Data Entry and Reporting Chapter is Chapter 24.

A hard copy is available in rooms G315 and G323.

There are currently four (4) synoptics used in Hematopathology. o Bone Marrow/Peripheral Blood Hematopoietic/Lymphoid Disorders Synoptic o Gastrointestinal Lymphoma Resection Synoptic o Hodgkin Lymphoma Biopsy/Staging Synoptic o Non-Hodgkin’s Lymphoma Biopsy/Resection Synoptic

OTHER

Never use tabs.

Do not change FONT or center justify header in IHC table.

LYMPH NODE/SOLID TISSUE ORGANIZATION OF SIGNOUT MATERIAL

http://copath.upmc.com/

(SLIDES, BLOCKS, PAPERWORK)

1.0 Principle

1.1 All material, whether in-house or consult, received fresh or fixed (glass slides and/or blocks) must be kept in an organized fashion with detailed records to facilitate efficient and accurate functioning of lymph node/solid tissue hematopathology sign out service.

2.0 Specimen Requirements

2.1 Specimens include all cases designated for hematopathology lymph node/solid tissue service.

3.0 Reagents, Supplies and Equipment

3.1 Reagents Not Applicable

3.2 Supplies

Hematopathology Case Worksheets 3.3 Equipment

Computer with Microsoft Office

4.0 Calibration and Standardization Not applicable

5.0 Quality Control

5.1 All problems noted in terms of special handling, transcription or histology will be entered under the “Adverse Event” section for each case in CoPath.

(See Appendix G - Adverse Event Recording) 6.0 Procedure

6.1 Throughout the day, all material for the lymph node service is brought into the lymph node sign out room (G323) to be distributed with the cases.

6.1.1 If formalin fixed H & E stained slides from tissue grossed and submitted the day before

are not received by 4:00PM, follow up with a call to histology laboratory to determine when the slides will be available (extension 647-7660).

6.2 Whenever slides are received, place on a tray with all other slides on the case together with all

paperwork and place on the microscope table.

6.2.1 If a Hematopathology Case Worksheet (Appendix B) already exists because the case was handled in the gross room or the sheet was filled out when the consult was accessioned/received, record which slides were received.

6.2.2 If a case does not already have a Hematopathology Case Worksheet, print one out

in Copath under the “Heme Worksheet” function.

6.2.3 Determine if any slides that should be present are missing by one of the following

methods:

6.2.3.1 Check gross description and current time. Rush formalin fixed and B+ fixed H&E

stains come out by the next day after submission. PAS should be out during the afternoon on the same day.

6.2.3.2 Check the Hematopathology Case Worksheet for date/time stains were ordered. Assuming the block is in histology, immunostains ordered before 9AM should be out late on the same day (does not always happen) and those ordered by 6PM should be out early the following day. In situ hybridization stains are typically expected in 2 days.

6.2.3.3 Print out the "CoPath Accession Log with stain information by specimen"

(Appendix H) after ordering the stains for the case. Check pending stains noting if all verified stains have been received. (If not, call histology/immunohistology laboratory ext 7-7663) and if all unverified stains are not overdue (See 6.3.3.1 and 6.3.3.2 for expected turn-around times and follow-up instructions).

6.2.3.3.1 Directions for CoPath called: “Accession Log with Information by Specimen”

1. Log onto CoPath. 2. Click on FILE in the menu bar. 3. Choose BROWSE ITEMS. 4. Under the Browse Items list, find the report "Accession Log w/Stain Info by

Specimen" 5. Click and drag the “Accession Log w/Stain Info by Specimen” report into your

menu on the left. 6. Double click on it to open the report. 7. The next time you log on, you will be able to directly access the report from

your menu list.

6.2.3.3.2 Directions for bringing up specific "Accession Log w/Stain Information" report:

1. Under Data Field, highlight "Specimen." 2. Choose Individual Items as selection method and type the specimen number in the "Select a Specimen" Box.

3. Click OK. 4. Under Data Field, for "Retrieval Flag","Stain/Process" and "Request Class", choose All Values as Selection Method.

5. Click OK and report will appear.

6.2.3.4 Attach copy of print out to Hematopathology Case Worksheet, with notation of any follow-up performed.

All cases (slides, paperwork, folder) will be kept in one of the following shelves:

Pending flow (inhouse or consult fresh tissue) Pending IHC cases (keep separated whether out today or the next day)

Pending receipt of requested outside blocks/blanks/slides (Go through at least every other day.) Pending H&E’s ONLY Pending Molecular and Cytogenetic studies Dictated, to Proof-read

Signed out cases, pending Immunostains/ISH/ MDX/ Cytogenetics for addendums

UPMC Page 1 of 4

Hematopathology Case Worksheet PHS13- PATIENT:

Blocks in Histology Blocks sent down to histology

Date/Time

Blanks sent down to histology

Date/Time

Requested Date:

Blocks

Blanks

Other

Contact:

ROUTINE STAINS/BLANKS

Stain Code Block(s) Requested Ordered Received Comments

H & E RHHE PAS HPAS Grocott HGRO AFB HAFT Blanks (# ) HBNKNC Congo Red HCNR Steiner HSTNC

IMMUNOSTAINS * = run stain process group

Stain Code Block(s) Requested Ordered Received Comments

Small B-Cell Panel

CD3, 20,5,10,43

BCL-2,BCL-6,cycD1

SBCP*

MALT Eval

anti-kappa, anti-lambda

CD20, BCL-2, CD43, CD5

BCL-6, CD10, cyclin D1, CD3

AMALTe*

DLBCL Eval

CD20, BCL-6, MUM-1

CD3, BCL-2, CD10

Cyclin D1, CD5, MYC, Ki-67

ADLBCL*

Cytoplasmic Ig-IHC

anti-kappa, anti-lambda

ACIG*

Cytoplasmic Ig-ISH

Kappa, Lambda, MRNA

ICIG*

Myeloma

Kappa BM, Lambda BM

CD138

AMyel*

Double k/lambda IKPLM * Ig Heavy Chains

anti-IgG,IgA, IgM, IgD

AIGH*

Anti-IgA AIGA Anti-IgD AIGD Anti-IgG AIGG Anti-IgG4 AIGG4 Anti-IgM AIGM CD20/L26 AL26 CD22 ACD22 CD79a ACD79 PAX 5 APAX5 CD21 ACD21 CD23 ACD23 CD138 CD138

UPMC Page 2 of 4

Hematopathology Case Worksheet

J chain AJ BCL2 ABCL2 BCL2 E17 ABCL2E17 MYC c-MYC BCL6 ABCL6 CD10 ACD10 IRF4/MUM-1 AMUM1 Cyclin D1 ACYCLD1 SOX-11 SOX11 P27 AP27 LEF-1/TCF-1 LEF-1 Annexin A1 AANNEX Mini-ALL TdT, CD34

AAllm*

TdT ATDT CD45/LCA ALCA Hodgkin's Panel

CD3, 20, 15, 30

EMA, LCA

AHODPP*

HL expanded

CD20, CD3, CD45/LCA,

CD30/Ber H2, CD15/Leu M1,

PAX 5, MUM-1,OCT-2, Bob.1, EMA

AHL*

OCT-2/Bob.1 AOCT* HL, extras

PAX5, MUM-1, OCT-2

Bob.1

AHLe*

CD15/Leu M1 ALEUM1 CD30/Ber H2 ACD30 EMA AEMA ALCL ALK-1, Clusterin

AALCL*

Alk-1 AALK1 Clusterin ACLUST Pan T-Cell/Basic subset

CD2, CD3, CD4, CD5

CD7, CD8

APANT*

T-cell subsets other Beta-F1, CD57, CD25, Granzyme B,

CD56, TIA1, PD-1, CXCL 13

ATCSS*

NK lymphoma

CD20/L26, CD2, CD3, CD5

CD7, Beta-F1, CD56, TIA1

Granzyme B

EBV-ISH (EBER)

ANKL*

CD1a ACD1a CD2 ACD2 CD3 ACD3 CD4 ACD4 CD5 ACD5 CD7 ACD7 CD8 ACD8

UPMC

CD43/Leu 22 ACD43 CD279/PD-1 PD1 CXCL13 ACXCL13 Beta-F1 ABF1 Gamma TCR CD56 ACD56 CD57/Leu 7 ALEU7 TIA1 ATIA Granzyme B. AGRANZ CD25 ACD25 Myeloblast eval

MPO, Lyso, Neut elast

CD117, CD34, TdT

AMyBe*

Myeloblast-limited

MPO, CD117, CD34, TdT

AMyBL*

Mini-Myeloblasts

CD117, CD34

AMyBm*

BM Lineage

CD68/PGM-1, MPO, CD34

Glycophorin A,Factor VIIIRA

ABML*

CD68/PGM-1 ACD68 CD123 CD123 TCL-1 TCL-1A Myeloperoxidase AMPO Lysozyme ALYSO CD14 CD14 CD163 CD163 CD33 ACD33 Neut. Elast ANE CD117 ACKIT Tryptase ATRYP CD34 ACD34 Glycophorin A AGLYP Factor VIIIRA AVWF CD61 ACD61B Ki-67/MIB-1 AKi67 P53 AP53 AE1/AE3 AAE13 Cam 5.2 ACAM Pankeratin APANKR S100/S100a AS100D CD207 / Langerin LANG EBV-ISH (EBER) IEBER * EBV-LMP AEBV Parvovirus APARVO CMV ACMV HHV8 AHHV8 H.Pylori HPYL Bartonella (CSD) BHENS Treponema ATREP Herpes Simplex 1/2 AHSV12

MOLECULAR

DNA/RNA (Already Stored) Frozen Blank Slides Available Order blanks - See Page One

TEST Req'd Ord'd Tissue/Slides Sent(date/time) Comments

Ig heavy chain and light chain gene rearrangment, PCR T-cell receptor gamma chain rearrangment, PCR T-cell receptor beta chain gene rearrangment, PCR JAK2 V617F BCR-ABL1 PML-RARA FLT3 & NPM1 CLL sequencing for somatic hypermutation

CYTOGENETICS Blank Slides Available Order Blanks - See Page One

Break Apart Rearrangement Probes Other

ALK (2p23) RARA (17q21) ASS deletion (9q34) AML1 (21q22) TCRB (7q34) ATM deletion (11q22.3) BCL2 (18q21) TCRG (7p14) CEP X/Y BCL3 (19q13) TCRAD (14q11) D7S486/CEP7 -7/7q31 I (7q) BCL6 (3q27) TCR3 (19p13) (D7S522/CEP7) - 7/7q31 BCL10 (1p22) TCL1(14q32.1) Deletion 13q (13q14) D135319 CBFB (16q22) Deletion 20q (20q12) D205108 CCND1 (11q13) Translocation Probes EGR1 -5/5q- ETV6 (TEL) (12p13) RUNX1T1/RUNX1 (ETO/AML1) t(8;21) AML FIP1L1-CHIC2-PDGFRA(4q12) (CHIC2 deletion) EVI1 (MECOM) (3q26.2) BIRC3-MALT1 (API2-MALT1) t(11;18) CDKN2A (p16) (9p21 deletion) EWSR1 (22q11.2) BCR-ABL t(9;22) CML/ALL/AML TP53 deletion (17p13.1) FGFR1 (8p12) IGH - CCND1 (T11:14) Trisomy 5, 9, 15 IGH (14q32) IGH-BCL2 t(14;18) Trisomy 8 D8Z2 IGK (2p11) CBFB-MYH1 (16p13/16q22) t(16;16). inv(16) Trisomy 12 D1273 IGL (22q11) IGH-FGFR3 t(4;14) MALT1 (18q21) IGH-MAF t(14;16) MLL (11q23) IGH MALT1 t(14;18) MYC (8q24) IGH-MYC t(8;14) MYCN (2P23-24) (for amp) PML-RARA t(15;17) PAX5 (9p13) TEL-AML1 (ETV6/RUNX1) t(12;21) PDGFRB (5q33)

Panels B-Cell Lymphoma - BCL6 (3q27) / MYC (8q24) / IGH (14q32.3) / BCL2 (18q21) CLL - MYB (6q23) / ATM (11q22.3) / trisomy 12 / D13S319 (13q14.3) / IGH (14q32.3) / p53 (17p13.1) Multiple Myeloma MM - D13S319 (13q14.3) / ATM (11q22.3) / p53 (17p13.1) / IGH (14q32.3) / CCND1 (11q13) Childrens' ALL - CEP4/CEP10/CEP17 (trisomies 4, 10, 17) / BCR/ABL [t(9;22)] / MLL (11q23) / TEL-AML1 (ETV6/RUNX1) t((12;21) Childrens' AML - EGR1 (5q31) / monosomy 7 / ETO-AML1 (RUNX1T1/RUNX1) [t(8;21)] / MLL (11q23) / CBFB [inv(16)] MDS/AML - EGR1 (5q31) / D7S486 (7q31)-CEP7 / trisomy 8 / D2OS108 (20q12) AML Panel - EGR1 (5q31) / D7Z1 - D7S486 / RUNX1T1-RUNX1[t(8;21)] / CBFB [inv(16) or t(16;16)] / MLL [t(11;var)] [as needed (i.e. if not seen by classical analysis)]

MPD panel - BCR-ABL1 / CEP8 / CEP9 / D2OS108 (20q12) Myeloid/lymphoid neoplasm with eosinophilia - FIP1L1-CHIC2-PDGFRA (4q12), PDGFRB (5q33), FGFR1 (8p13)

Additional FISH Probes Request (please list) Requested Ordered Blanks Sent Comments

Filing of Slides

Location of Lymph Node slides

Before 1992 (LN were part of Surgical Pathology Section) - Iron Mountain

SEPT 1992 to PHS13-31654 - Iron Mountain

PHS13-31654 - present -G325.1 Bone marrow

Reading room PUH

Starting April, 2009 - LN surgical pathology requisitions are stored in the CLB, in room 9032,

near the grossing station.

Lymph Node Rotation Checklist


Orientation with (Fellowship Director) or designate.

Orientation with Dr. Gibson (Resident Director) or designate.

Done prior rotation

New rotation

Orientation by experienced trainee.

Done prior rotation

Orientation by Lymph Node Assistant or designate.

Done prior rotation

Competent and comfortable with gross processing and triaging of fresh lymph nodes and spleens and other specimens with possible hematopoietic/lymphoid disorders.

Competent and comfortable to construct, dictate and proof full reports and to order stains using CoPath.

Knows normal architecture and immunoarchitecture of lymph node, spleen and Peyer’s Patch.

Knows reactivity of all antibodies used in flow cytometry panel to assess hematopoietic/lymphoid disorders in lymph node, spleen and all other extranodal sites (panels in resident/fellow handbook).

Confidently can interpret flow cytometry data including histograms.

Knows role of cytogenetic and molecular diagnostic studies in evaluating hematopoietic/lymphoid disorder in lymph node, spleen and other extranodal sites.

Learned diagnostic criteria using multiparameter approach and clinical implications for

each of the following in lymph nodes and extranodal sites (residents to accomplish at least lower case items in bold, fellows to accomplish all over one year):


Actual Case


Read about

NON-NEOPLASTIC DISORDERS (NODAL)

Viral-associated adenitis (infectious mononucleosis, postvaccinal, herpes zoster, cytomegalovirus, measles, HIV)

Syphilis

Toxoplasmosis


Actual Case


Read about

Cat-scratch disease

Granulomatous processes

Whipple’s disease

Bacillary angiomatosis

Autoimmune disorders (Rheumatoid arthritis, Sjögren’s syndrome, Adults Still’s disease, systemic lupus erythematosus)

Sarcoidosis

Angiofollicular hyperplasia/Castleman’s Disease

Inflammatory pseudotumor

Dermatopathic lymphadenopathy

Sinus histiocytosis with massive adenopathy (Rosai-Dorfman)

Histiocytic Necrotizing Lymphadenitis

Kimura’s disease/angiolymphoid hyperplasia with eosinophilia

Drug reactions (Dilantin, Tegretol)

Hemophagocytic syndrome

Immunodeficiency states (including ALPS, other)

MALIGNANT LYMPHOMAS

B lymphoblastic leukaemia/lymphoma

T lymphoblastic leukaemia/lymphoma

Chronic lymphocytic leukaemia/small lymphocytic lymphoma


Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma)

Nodal marginal zone lymphoma


Actual Case


Read about

Follicular lymphoma

Primary cutaneous follicle centre lymphoma


Diffuse large B-cell lymphoma (DLBCL), NOS

T-cell/histiocyte rich large B-cell lymphoma

Primary DLBCL of the CNS

Primary cutaneous DLBCL, leg type

EBV positive DLBCL of the elderly

DLBCL associated with chronic inflammation

Lymphomatoid granulomatosis

Primary mediastinal (thymic) large B-cell lymphoma


ALK positive DLBCL

Plasmablastic lymphoma

Large B-cell lymphoma arising in associated multicentric Castleman disease

Primary effusion lymphoma

Burkitt lymphoma

High grade B-Cell lymphoma, MYC and BCL2 and/or BCL6 rearrangements (High grade B-cell lymphoma, NOS)

B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma and classical Hodgkin lymphoma

Adult T-cell leukaemia/lymphoma

Extranodal NK/T cell lymphoma, nasal type

Enteropathy-associated T-cell lymphoma


Actual Case


Read about


Subcutaneous panniculitis-like T-cell lymphoma

Mycosis fungoides

Sézary syndrome

Primary cutaneous CD30 positive T-cell lymphoproliferative disorders

Lymphomatoid papulosis

Primary cutaneous anaplastic large lymphoma

Primary cutaneous gamma-delta T-cell lymphoma

Primary cutaneous CD8 positive aggressive epidermotropic

Primary cutaneous CD4 positive small/medium T-cell lymphoma

Peripheral T-cell lymphoma, NOS


Anaplastic large cell lymphoma, ALK positive

Anaplastic large cell lymphoma, ALK negative

Nodular lymphocyte predominant Hodgkin lymphoma


POST-TRANSPLANT LYMPHOPROLIFERATIVE

DISORDER

Early lesions

Plasmacytic hyperplasia

Infectious-mononucleosis-like PTLD

Polymorphic PTLD

Monomorphic PTLD, B-cell types, T-cell types

Hodgkin lymphoma type PTLD

HISTIOCYTIC AND DENDRITIC CELL

NEOPLASMS


Actual Case


Read about

Histiocytic sarcoma

Langerhans cell histiocytosis/sarcoma

Interdigitating dendritic cell sarcoma

Follicular dendritic cell sarcoma

OTHER NEOPLASMS

Mastocytosis

Myeloid sarcoma

Blastic Plasmacytoid dendritic cell tumor

Metastatic tumors

Learned diagnostic criteria for the following in the SPLEEN (residents to accomplish at least items in lower case bold, fellows to accomplish all over one year):

Diagnosis / Finding



Read about

BENIGN

Localized lymphoid hyperplasia

Changes in benign systemic and infectious disorders

Rheumatoid arthritis (Felty’s syndrome)

Autoimmune thrombocytopenic purpura

Thrombotic thrombocytopenic purpura

Hereditary spherocytosis

Acquired immune deficiency syndrome

Bacterial infections including bacillary angiomatosis

Viral infections including infectious mononucleosis

Castleman disease

Fibrocongestive splenomegaly

Histiocytic proliferations

Lipid histiocytes

Ceroid histiocytosis

Gaucher’s disease


Hemophagocytic syndrome

SPLENIC EXPRESSION OF THE FOLLOWING LYMPHOMAS

Chronic lymphocytic leukemia / Small lymphocytic lymphoma



Splenic and other marginal zone B-cell lymphomas

Splenic lymphoma/leukaemia, unclassifiable

Follicular lymphoma

Diffuse large B-cell lymphoma


Other non-Hodgkin’s lymphomas

Prolymphocytic leukemia

Large granular lymphocytic leukemia

CHANGES IN LEUKEMIAS AND MYELOPROLIFERATIVE DISORDERS

Chronic myeloid leukemia

Chronic myeloproliferative neoplasm

Hairy cell leukemia

Acute leukemias

Systemic mastocytosis

NONHEMATOPOIETIC LESIONS

Developmental cysts

Developmental hamartomas

Vascular neoplasms

Hemangiomas

Lymphangiomas

Littoral-cell angiomas

Angiosarcomas

Nonvascular sarcomas

Metastases

Inflammatory pseudotumor

PRESENTED THE FOLLOWING “LYMPH NODE” CASES (Submit Presentation in Portfolio).

PHS NUMBER DIAGNOSIS

UTILIZED THE FOLLOWING LYMPH NODE RESOURCES Lymph node chapter in Sternberg.

Swerdlow, S.H., Campo, E., Harris, N.L., Jaffe, E., Pileri, S.A., Stein, H., Thiele, J., Vardiman, J.

(Eds.): WHO Classification of Tumours Pathology of Haematopoietic and Lymphoid Tumours, IARC, Lyon, 2008. [Highly recommended]

Checkpath (images, histories and explanations of faculty CME program for Hematopathology)

(PUH G315 and in Dr. Swerdlow’s coordinator’s office). Teaching/conference sets of glass slides of marrows, lymph nodes, etc. (Dr. Swerdlow’s office).

Jaffe, E.S., Harris, N.L., H. Vardiman, J.W., Campo, E., Arber, Daniel A., Hematopathology,

2011 (G323)

O’Malley D.P., George, T.I., Orazi A., Benign and Reactive Conditions of Lymph Node and Spleen, 2009.

NOTE: Reading is an important component of this rotation. It is recognized that not all of the above resources can be used nor can most be read in entirety. Use of electronic and other resources to find and read up-to-date journal articles is also critical.

I have completed the Lymph Node Checklist Name __________________________________________ (printed) __________________________________________ (signature) Date __________________________________________

Protocol for the Examination of Specimens From Patients With

Non-Hodgkin Lymphoma/Lymphoid Neoplasms

Protocol applies to non-Hodgkin lymphoma/lymphoid neoplasms involving any site

except the ocular adnexa, bone marrow, mycosis fungoides, and Sezary syndrome.

Based on AJCC/UICC TNM, 7th Edition

Protocol web posting date: October 2013

Procedures

• Biopsy

• Resection of Lymph Node(s) or Other Organ(s)

Authors Jerry W. Hussong, MD, DDS, FCAP*

Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California

Daniel A. Arber, MD

Department of Pathology, Stanford University School of Medicine, Stanford, California

Kyle T. Bradley MD, MS, FCAP

Department of Pathology and Laboratory Medicine, Emory University Hospital, Atlanta, Georgia


Department of Pathology, Yellowstone Pathology Institute Inc, Billings, Montana

Chung-Che Chang, MD, PhD, FCAP

Department of Pathology, The Methodist Hospital, Houston, Texas

Monica E. de Baca, MD, FCAP

Department of Pathology and Laboratory Medicine, Physicians Laboratory Ltd, Sioux Falls, South Dakota

David W. Ellis, MBBS, FRCPA

Department of Anatomical Pathology, Flinders Medical Centre, Bedford Park, South Australia

Kathryn Foucar, MD, FCAP

Department of Pathology, University of New Mexico, Albuquerque, New Mexico

Eric D. Hsi, MD, FCAP

Department of Clinical Pathology, Cleveland Clinic Foundation, Cleveland, Ohio

Elaine S. Jaffe, MD

Hematopathology Section, Laboratory of Pathology, National Cancer Institute, Bethesda, Maryland

Joseph Khoury, MD, FCAP

MD Anderson Cancer Center, Houston, Texas


Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California

Stephen P. McClure, MD

Department of Pathology and Laboratory Medicine, Presbyterian Pathology Group, Charlotte, North

Carolina

L. Jeffrey Medeiros, MD, FCAP

Department of Hematopathology, MD Anderson Cancer Center, Houston, Texas


Department of Pathology, Hematopathology, University of Utah Health Sciences Center, Salt Lake City,

Utah

For the Members of the Cancer Committee, College of American Pathologists

* Denotes the primary and senior author. All other contributing authors are listed alphabetically.

Surgical Pathology Cancer Case Summary

Protocol web posting date: October 2013

NON-HODGKIN LYMPHOMA/LYMPHOID NEOPLASMS: Biopsy, Resection

Select a single response unless otherwise indicated.

Specimen (select all that apply) (note A)

Lymph node(s)

Other (specify):

Not specified

Procedure

Biopsy

Resection

Other (specify):

Not specified

Tumor Site (select all that apply) (note B)

Lymph node(s), site not specified

Lymph node(s)

Specify site(s):

Other tissue(s) or organ(s):

Not specified

Histologic Type (note C)

Histologic type cannot be assessed

Precursor Lymphoid Neoplasms

B lymphoblastic leukemia/lymphoma, not otherwise specified (NOS)#

B lymphoblastic leukemia/lymphoma with t(9;22)(q34;q11.2); BCR-ABL1

B lymphoblastic leukemia/lymphoma with t(v;11q23); MLL rearranged

B lymphoblastic leukemia/lymphoma with t(12;21)(p13;q22); TEL-AML1 (ETV6-RUNX1)

B lymphoblastic leukemia/lymphoma with hyperdiploidy

B lymphoblastic leukemia/lymphoma with hypodiploidy (hypodiploid acute lymphoblastic

leukemia/lymphoma [ALL])

B lymphoblastic leukemia/lymphoma with t(5;14)(q31;q32); IL3-IGH

B lymphoblastic leukemia/lymphoma with t(1;19)(q23;p13.3); E2A-PBX1 (TCF3-PBX1)

T lymphoblastic leukemia/lymphoma


B-cell lymphoma, subtype cannot be determined (Note: not a category within the WHO

classification)

Chronic lymphocytic leukemia/small lymphocytic lymphoma

B-cell prolymphocytic leukemia

Splenic B-cell marginal zone lymphoma

Hairy cell leukemia

Splenic B-cell lymphoma/leukemia, unclassifiable

Splenic diffuse red pulp small B-cell lymphoma

Hairy cell leukemia-variant


Gamma heavy chain disease

Mu heavy chain disease

Alpha heavy chain disease

Plasma cell myeloma

Solitary plasmacytoma of bone

Extraosseous plasmacytoma

Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma)

Nodal marginal zone lymphoma

Pediatric nodal marginal zone lymphoma

Follicular lymphoma

Pediatric follicular lymphoma

Primary intestinal follicular lymphoma

Primary cutaneous follicle center lymphoma


Diffuse large B-cell lymphoma (DLBCL), NOS

T cell/histiocyte-rich large B-cell lymphoma

Primary DLBCL of the central nervous system (CNS)

Primary cutaneous DLBCL, leg type

Epstein-Barr virus (EBV)-positive DLBCL of the elderly

DLBCL associated with chronic inflammation

Lymphomatoid granulomatosis

Primary mediastinal (thymic) large B-cell lymphoma


Anaplastic lymphoma kinase (ALK)-positive large B-cell lymphoma

Plasmablastic lymphoma

Large B-cell lymphoma arising in HHV8-associated multicentric Castleman disease

Primary effusion lymphoma

Burkitt lymphoma

B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma

and Burkitt lymphoma

B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma

and classical Hodgkin lymphoma

Other (specify):

Mature T- and NK-Cell Neoplasms

T-cell lymphoma, subtype cannot be determined (Note: not a category within the WHO

classification)

T-cell prolymphocytic leukemia

T-cell large granular lymphocytic leukemia

Chronic lymphoproliferative disorder of NK cells

Aggressive NK-cell leukemia

Systemic EBV-positive T-cell lymphoproliferative disease of childhood

Hydroa vacciniforme-like lymphoma

Adult T-cell leukemia/lymphoma

Extranodal NK/T-cell lymphoma, nasal type

Enteropathy-associated T-cell lymphoma


Subcutaneous panniculitis-like T-cell lymphoma

Primary cutaneous anaplastic large cell lymphoma

Lymphomatoid papulosis

Primary cutaneous gamma-delta T-cell lymphoma

Primary cutaneous CD8-positive aggressive epidermotropic cytotoxic T-cell lymphoma

Primary cutaneous CD4-positive small/medium T-cell lymphoma

Peripheral T-cell lymphoma, NOS


Anaplastic large cell lymphoma, ALK-positive

Anaplastic large cell lymphoma, ALK-negative

Other (specify):

Histiocytic and Dendritic Cell Neoplasms

Histiocytic sarcoma


Langerhans cell sarcoma

Interdigitating dendritic cell sarcoma

Follicular dendritic cell sarcoma

Fibroblastic reticular cell tumor

Indeterminate dendritic cell tumor

Disseminated juvenile xanthogranuloma

Posttransplant Lymphoproliferative Disorders (PTLD)##

Early lesions:

Plasmacytic hyperplasia

Infectious mononucleosis-like PTLD

Polymorphic PTLD

Monomorphic PTLD (B- and T/NK-cell types)

Specify subtype:

Classical Hodgkin lymphoma type PTLD###

Note: Italicized histologic types denote provisional entities in the 2008 WHO classification.

# An initial diagnosis of “B lymphoblastic leukemia/lymphoma, NOS” may need to be given before the cytogenetic

results are available.

## These disorders are listed for completeness, but not all of them represent frank lymphomas.

### Classical Hodgkin lymphoma type PTLD can be reported using either this protocol or the separate College of

American Pathologists protocol for Hodgkin lymphoma.1

+ Pathologic Extent of Tumor (select all that apply) (note D)

+ Bone marrow involvement

+ Other site involvement

+ Specify site(s):

+ Additional Pathologic Findings

+ Specify:

Immunophenotyping (flow cytometry and/or immunohistochemistry) (note E)

Performed, see separate report:

Performed

Specify method(s) and results:

Not performed

+ Cytogenetic Studies (note E)

+ Performed, see separate report:

+ Performed

+ Specify method(s) and results:

+ Not performed

+ Molecular Genetic Studies (note E)

+ Performed, see separate report:

+ Performed

+ Specify method(s) and results:

+ Not performed

+ Clinical Prognostic Factors and Indices (select all that apply) (note F)

+ International Prognostic Index (IPI) (specify):

+ Follicular Lymphoma International Prognostic Index (FLIPI) (specify):

+ B symptoms present

+ Other (specify):

+ Comment(s)

+ Data elements preceded by this symbol are not required. However, these elements may be clinically important but are not yet

validated or regularly used in patient management.

Explanatory Notes

A. Specimen

Any number of specimen types may be submitted in the evaluation of lymphoid neoplasms. Lymph

nodes, skin, gastrointestinal (GI) tract, bone marrow, spleen, thymus, and tonsils are among the most

common. Specimens submitted with a suspected diagnosis of lymphoma require special handling in

order to optimize the histologic diagnosis and to prepare the tissue for molecular and other ancillary

special studies.2,3 The guidelines detailed below are suggested for specimen handling in cases of

suspected lymphoma.

• Tissue should be received fresh. Unsectioned lymph nodes should not be immersed in fixative, and

care should be taken to make thin slices of the node to ensure optimal penetration of fixative.

• The fresh specimen size, color, and consistency should be recorded, as should the presence or

absence of any visible nodularity, hemorrhage, or necrosis after serial sectioning at 2-mm intervals

perpendicular to the long axis of the lymph node.

• Touch imprints may be made from the freshly cut surface, and the imprints fixed in alcohol or air

dried.

• For cytogenetic studies or culture of microorganisms: submit a fresh portion of the node (or other

specimen type) sterilely in appropriate medium.

• For immunophenotyping by flow cytometry: submit a fresh portion of the specimen in appropriate

transport medium such as RPMI.

• Fixation (record fixative[s] used for individual slices of the specimen):

o Estimated time from excision to fixation should be noted, if possible, as this may impact

preservation or recovery of certain analytes such as RNA and phosphoproteins in fixed tissues.

o Zinc formalin or B5 produces superior cytologic detail but is not suitable for DNA extraction and

may impair some immunostains (eg, CD30). B5 also has the additional limitation of requiring

proper hazardous-materials disposal.

o Formalin fixation is preferable when the tissue sample is limited, as it is most suitable for many

ancillary tests such as molecular/genetic studies, in-situ hybridization, and immunophenotyping.

o Over-fixation (ie, more than 24 hours in formalin, more than 4 hours in zinc formalin or B5) should

be avoided for optimal immunophenotypic reactivity.

• Snap-frozen tissue is optimal for DNA and RNA extraction.

o Place in aluminum foil or cover in OCT.

o Immerse in dry ice/isopentane slush or liquid nitrogen.

o Store at -80°C until needed.

B. Tumor Site

The anatomic sites that constitute the major structures of the lymphatic system include groups and

chains of lymph nodes, the spleen, the thymus, Waldeyer’s ring (a circular band of lymphoid tissue that

surrounds the oropharynx, consisting of the palatine, lingual, and pharyngeal tonsils), the vermiform

appendix, and the Peyer’s patches of the ileum.2,3 Minor sites of lymphoid tissue include the bone

marrow, mediastinum, liver, skin, lung, pleura, and gonads. Involvement of extranodal sites is more

common in non-Hodgkin lymphomas (NHL) than in Hodgkin lymphoma. In addition, some NHL, such as

mycosis fungoides and extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue

(MALT), occur predominantly or entirely in extranodal sites.

C. Histologic Type

This protocol recommends assigning histologic type based on the World Health Organization (WHO)

classification of lymphoid neoplasms.4 It was originally published in 2001 and recently was revised and

updated in 2008.5 This classification encompasses both nodal and extranodal lymphomas and provides

distinction of individual lymphoid neoplasms based upon morphologic, immunophenotypic,

cytogenetic, and clinical features. While histologic examination typically is the gold standard, the

majority of the lymphoid neoplasms will require the utilization of 1 or more other ancillary techniques,

such as immunophenotyping, molecular studies, and/or cytogenetics, to arrive at the correct

diagnosis.4-10 If the specimen is inadequate or suboptimal for a definitive diagnosis and subtyping, this

information should also be relayed to the clinician with an explanation of what makes the specimen

inadequate or suboptimal.

D. Pathologic Extent of Tumor (Stage)

In general, the TNM classification has not been used for staging of lymphomas because the site of origin

of the tumor is often unclear and there is no way to differentiate among T, N, and M. Thus, a special

staging system (Ann Arbor system) is used for both Hodgkin lymphoma and NHL.11,12 It was originally

published over 30 years ago for staging Hodgkin lymphoma. The Ann Arbor classification for

lymphomas has been applied to NHL by the American Joint Committee on Cancer (AJCC)13 and the

International Union Against Cancer (UICC) except for mycosis fungoides and Sezary syndrome.14

For multiple myeloma, the Durie-Salmon staging system is recommended by the AJCC.13-15 The

international staging system for multiple myeloma is useful for determining survival.13 The Ann Arbor

classification and Durie-Salmon staging systems are shown below. It should also be realized that the St.

Jude staging system is commonly used for pediatric patients.16

Historically, pathologic staging depended on the biopsy of multiple lymph nodes on both sides of the

diaphragm, splenectomy, wedge liver biopsy, and bone marrow biopsy to assess distribution of disease.

Currently, staging of NHL is more commonly clinical than pathologic. Clinical staging generally involves

a combination of clinical, radiologic, and surgical data. Physical examination, laboratory tests (eg,

complete blood examination and blood chemistry studies including lactate dehydrogenase [LDH] and

liver function tests), imaging studies (eg, computed tomography scans, magnetic resonance imaging

studies, and positron emission tomography), biopsy (to determine diagnosis, histologic type, and extent

of disease), and bone marrow examination are often required. In patients at high risk for occult CNS

involvement, cerebrospinal fluid cytology should be performed.

There is almost universal agreement that the stage of the NHL is prognostically significant.17-20

Correct

diagnosis and staging are the key factors in National Comprehensive Cancer Network treatment

schema that most clinicians utilize.21

AJCC/UICC Staging for Non-Hodgkin Lymphomas

Stage I Involvement of a single lymph node region (I), or localized involvement of a single

extralymphatic organ or site in the absence of any lymph node involvement (IE)#, ##

Stage II Involvement of 2 or more lymph node regions on the same side of the diaphragm (II), or

localized involvement of a single extralymphatic organ or site in association with regional

lymph node involvement with or without involvement of other lymph node regions on

the same side of the diaphragm (IIE) ##,###

Stage III Involvement of lymph node regions on both sides of the diaphragm (III), which also may

be accompanied by extralymphatic extension in association with adjacent lymph node

involvement (IIIE) or by involvement of the spleen (IIIS) or both (IIIE+S) ##,###,^

Stage IV Diffuse or disseminated involvement of 1 or more extralymphatic organs, with or without

associated lymph node involvement; or isolated extralymphatic organ involvement in

the absence of adjacent regional lymph node involvement, but in conjunction with

disease in distant site(s). Stage IV includes any involvement of the liver, bone marrow, or

nodular involvement of the lung(s) or cerebral spinal fluid. ##,###,^

# Multifocal involvement of a single extralymphatic organ is classified as stage IE and not stage IV.

## For all stages, tumor bulk greater than 10 to 15 cm is an unfavorable prognostic factor.

### The number of lymph node regions involved may be indicated by a subscript: eg, II3. For stages II to

IV, involvement of more than 2 sites is an unfavorable prognostic factor.

^ For stages III to IV, a large mediastinal mass is an unfavorable prognostic factor.

Note: Direct spread of a lymphoma into adjacent tissues or organs does not influence classification of

stage.

AJCC/UICC Staging for Plasma Cell Myeloma

Stage I Hemoglobin greater than 10.0 g/dL

Serum calcium 12 mg/dL or less

Normal bone x-rays or a solitary bone lesion

IgG less than 5 g/dL

IgA less than 3 g/dL

Urine M-protein less than 4 g/24 hours

Stage III One or more of the following are included:

Hemoglobin less than 8.5 g/dL

Serum calcium greater than 12 mg/dL

Advanced lytic bone lesions

IgG greater than 7 g/dL

IgA greater than 5 g/dL

Urine M-protein greater than 12 g/24 hours

Stage II Disease fitting neither stage I nor stage III

Note: Patients are further classified as (A) serum creatinine less than 2.0 mg/dL or (B) serum creatinine

2.0 mg/dL or greater. The median survival for stage IA disease is about 5 years, and that for stage IIIB

disease is 15 months.13,14

E. Immunophenotyping and Molecular Genetic Studies

Immunophenotyping can be performed by flow cytometry8 or immunohistochemistry. Each has its

advantages and disadvantages. Flow cytometry is rapid (hours), quantitative, and allows multiple

antigens to be evaluated on the same cell simultaneously. Antigen positivity, however, cannot be

correlated with architecture or cytologic features. Immunohistochemistry requires hours/days to

perform, quantitation is subjective, but importantly it allows correlation of antigen expression with

architecture and cytology. Not all antibodies are available for immunohistochemistry, particularly in

fixed tissues, but one of its advantages is that it can be performed on archival tissue. Both techniques

can provide diagnostic as well as clinically relevant information (eg, identification of therapeutic targets

such as CD20). Molecular studies now play an increasingly important role in the diagnosis of

hematopoietic neoplasms. They aid not only in helping establish clonality but also in determining

lineage, establishing the diagnosis of specific disease entities, and monitoring minimal residual

disease.10,22-24

Immunophenotypes and Genetics

The following is to be used as a guideline for the more common immunophenotyping and cytogenetic

findings for each entity.3,4,8,22-27 It is however, not entirely comprehensive and individual cases may vary

somewhat in their immunophenotypic and cytogenetic profile.

Precursor Lymphoid Neoplasms

B Lymphoblastic Leukemia/Lymphoma, NOS: sIG-, cytoplasmic µ chain (30%), CD19+, CD20-/+, CD22+,

PAX5+, CD79a+, TdT+, HLA-DR+, CD10+/-, CD34+/-, CD13-/+, CD33-/+, IGH gene rearrangement +/-, IGL

gene rearrangement -/+, TCR gene rearrangement -/+, variable cytogenetic abnormalities

B Lymphoblastic Leukemia/Lymphoma With t(9;22)(q34;q11.2); BCR-ABL1: sIG-, cytoplasmic µ chain

(30%), CD19+, CD20-/+, CD22+, PAX5+, CD79a+, TdT+, HLA-DR+, CD10+/-, CD34+/-, CD13-/+, CD33-/+,

IGH gene rearrangement +/-, IGL gene rearrangement -/+, TCR gene rearrangement -/+,

t(9;22)(q34;q11.2), may have either p190 kd or p210 kd BCR-ABL1 fusion protein.

B Lymphoblastic Leukemia/Lymphoma With t(v;11q23); MLL Rearranged: sIG-, cytoplasmic µ chain

(30%), CD19+, CD20-/+, CD22+, PAX5+, CD79a+, TdT+, HLA-DR+, CD10-, CD34+/-, CD13-/+, CD33-/+,

CD15 +/-, IGH gene rearrangement +/-, IGL gene rearrangement -/+, TCR gene rearrangement -/+,

t(v;11q23)

B Lymphoblastic Leukemia/Lymphoma With t(12;21)(p13;q22); TEL-AML1 (ETV6-RUNX1): sIG-, cytoplasmic

µ chain (30%), CD19+, CD20-, CD22+, PAX5+, CD79a+, TdT+, HLA-DR+, CD10+, CD34+/-, CD13+/-, CD33-

/+, CD15 +/-, IGH gene rearrangement +/-, IGL gene rearrangement -/+, TCR gene rearrangement -/+,

t(12;21)(p13;q22)

B Lymphoblastic Leukemia/Lymphoma With Hyperdiploidy: sIG-, cytoplasmic µ chain (30%), CD19+,

CD20-/+, CD22+, PAX5+, CD79a+, TdT+, HLA-DR+, CD10+/-, CD34+/-, CD13-/+, CD33-/+, IGH gene

rearrangement +/-, IGL gene rearrangement -/+, TCR gene rearrangement -/+, hyperdiploid (>50

chromosomes, often with extra copies of chromosomes 21, X, 4 and 14) without structural abnormalities

B Lymphoblastic Leukemia/Lymphoma With Hypodiploidy: sIG-, cytoplasmic µ chain (30%), CD19+,

CD20-/+, CD22+, PAX5+, CD79a+, TdT+, HLA-DR+, CD10+/-, CD34+/-, CD13-/+, CD33-/+, IGH gene

rearrangement +/-, IGL gene rearrangement -/+, TCR gene rearrangement -/+, hypodiploid with 45

chromosomes to near haploid

B Lymphoblastic Leukemia/Lymphoma With t(5;14)(q31;q32); IL3-IGH: sIG-, cytoplasmic µ chain (30%),

CD19+, CD20-, CD22+, PAX5+, CD79a+, TdT+, HLA-DR+, CD10+, CD34+/-, CD13+/-, CD33-/+, CD15 +/-,

IGH gene rearrangement +/-, IGL gene rearrangement -/+, TCR gene rearrangement -/+,

t(5:14)(q31;q32)

B Lymphoblastic Leukemia/Lymphoma With t(1;19)(q23;p13.3); E2A-PBX1 (TCF3-PBX1): sIG-, cytoplasmic

µ chain (30%), CD19+, CD20-, CD22+, PAX5+, CD79a+, TdT+, HLA-DR+, CD10+, CD34+/-, CD13+/-, CD33-

/+, CD15 +/-, IGH gene rearrangement +/-, IGL gene rearrangement -/+, TCR gene rearrangement -/+,

t(1;19)(q23;p13.3)

T Lymphoblastic Leukemia/Lymphoma: TdT+, CD7+, CD3+/- (usually surface CD3-), variable expression

of other PanT antigens, CD1a+/-, often CD4 and CD8 double positive or double negative, IG-, PanB-;

variable TCR gene rearrangements; IGH gene rearrangement -/+, chromosomal abnormalities are

common and often involve 14q11-14, 7q35, or 7p14-15


Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma: Faint sIGM+, sIGD+/-,

cIG-/+, panB+ (CD19+, CD20+), CD5+, CD10-, CD23+, CD43+, CD11c-/+; IGH and IGL gene

rearrangements; trisomy 12; del 13q, del(17p), or del(11q) can be seen

B-Cell Prolymphocytic Leukemia: sIgM, sIgD+/-, pan B+ (CD19, CD20, CD22, CD79a, CD79b and FMC-7),

CD5 -/+, CD23-/+, del(17p), t(11;14)(q13;q32), breakpoints involving 13q14

Splenic B-Cell Marginal Zone Lymphoma: sIGM+, sIGD+/-, CD20+, CD79a+, CD5-, CD10-, CD23-, CD43-,

nuclear cyclin D1-, CD103-, allelic loss at 7q31-32 (40%)

Hairy Cell Leukemia: sIG+ (IGM, IGD, IGG, or IGA), PanB+, CD79a+, CD79b-, DBA.44+, CD123+, CD5-,

CD10-, CD23-, CD11c+, CD25+, FMC7+, CD103+ (mucosal lymphocyte antigen as detected by B-ly7),

tartrate resistant acid phosphatase (TRAP)+; IGH and IGL gene rearrangements, no specific cytogenetic

findings

Splenic Diffuse Red Pulp Small B-Cell Lymphoma: sIGG+, sIGD-/+, sIGM+/-, CD20+, DBA.44+, CD5-,

CD103-/+, CD123-, CD25-, CD11c-/+, CD10-, CD23-, t(9;14)(p13;q32) occasionally seen, rarely

abnormalities in TP53 or del 7q

Hairy Cell Leukemia-Variant: sIGG+, PanB+, DBA.44+, CD11c+, CD103+, FMC7+, CD25-, CD123-, Annexin

A1-, TRAP-IHC-, no specific cytogenetic findings

Lymphoplasmacytic Lymphoma: sIGM+, sIGD-/+, cIG+, PanB+, CD19+, CD20+, CD138+ (in plasma

cells), CD79a+, CD5-, CD10-, CD43+/-, CD25-/+; IGH and IGL gene rearrangements, no specific

cytogenetic findings

Alpha Heavy Chain Disease (Immunoproliferative Small Intestinal Disease): cytoplasmic alpha heavy

chain+, CD20+ (lymphocytes), CD138+ (plasma cells), light chain-

Gamma Heavy Chain Disease: IgG heavy chain+, CD79a+, CD20+ (on lymphocytes), CD138+ (in

plasma cells), CD5-, CD10-, light chain-, abnormal karyotype in 50% without recurring abnormalities

Mu Heavy Chain Disease: monoclonal cytoplasmic mu heavy chain+, B-cell antigen+, CD5-, CD10-,

surface light chain-

Plasma Cell Myeloma: cIG+ (IGG, IGA, rare IGD, IGM, or IGE or light chain only), PanB-(CD19-, CD20-,

CD22-), CD79a+/-, CD45-/+, HLA-DR-/+, CD38+, CD56+/-, CD138+, EMA-/+, CD43+/-, cyclin D1+; IGH

and IGL gene rearrangements; numerical and structural chromosomal abnormalities are common,

including trisomies (often involving odd numbered chromosomes), deletions (most commonly involving

13q14), and translocations (often involving 14q32)

Solitary Plasmacytoma of Bone: cIG+ (IGG, IGA, rare IGD, IGM, or IGE or light chain only), PanB-(CD19-,

CD20-, CD22-), CD79a+/-, CD45-/+, HLA-DR-/+, CD38+, CD56+/-, CD138+, EMA-/+, CD43+/-, cyclin D1+;

IGH and IGL gene rearrangements; deletions, most commonly 13q, and occasional translocations, in

particular t(11;14)(q13;q32)

Extraosseous Plasmacytoma: cIG+ (IGG, IGA, rare IGD, IGM, or IGE or light chain only), PanB-(CD19-,

CD20-, CD22-), CD79a+/-, CD45-/+, HLA-DR-/+, CD38+, CD56+/-, CD138+, EMA-/+, CD43+/-, cyclin D1+;

IGH and IGL gene rearrangements; deletions, most commonly 13q, and occasional translocations, in

particular t(11;14)(q13;q32)

Extranodal Marginal Zone Lymphoma of Mucosa-Associated Lymphoid Tissue

(MALT Lymphoma): sIG+ (IGM or IGA or IGG), sIGD-, cIG-/+, PanB+, CD5-, CD10-, CD23-, CD43-/+; IGH

and IGL gene rearrangements, BCL1 and BCL2 germline, trisomy 3 or t(11;18)(q21;q21) may be seen

Nodal Marginal Zone Lymphoma: sIGM+, sIGD-, cIG-/+, PanB+, CD5-, CD10-, CD23-, CD43-/+; IGH and

IGL gene rearrangements, BCL1 and BCL2 germline

Follicular Lymphoma: sIG+ (usually IGM +/- IGD, IGG, IGA), PanB+, CD10+/-, CD5-/+, CD23-/+, CD43-,

CD11c-, CD25-; overexpression of BCL2+ (useful to distinguish from reactive follicles), BCL6+; IGH and IGL

gene rearrangements, t(14;18)(q32;q21) with rearranged BCL2 gene (70-95% in adults)

Pediatric Follicular Lymphoma: sIG+ (usually IGM +/- IGD, IGG, IGA), PanB+, CD10+/-, CD5-, CD23-/+,

CD43-, CD11c-, CD25-; overexpression of BCL2-, BCL6+, t(14;18) with rearranged BCL2 gene -

Primary Cutaneous Follicle Center Lymphoma: CD20+, CD79a+, CD10+/-, BCL2-/+, BCL6+, CD5-, CD43-,

BCL2 gene rearrangement-/+

Mantle Cell Lymphoma: sIGM+, sIGD+, lambda>kappa, PanB+, CD5+, CD10-/+, CD23-, CD43+, CD11c-,

CD25-, cyclin D1+; IGH and IGL gene rearrangements, t(11;14)(q13;q32); BCL1 gene rearrangements

(CCND1/cyclinD1) common

Diffuse Large B-Cell Lymphoma (DLBCL), NOS: PanB+, surface or cytoplasmic IGM>IGG>IGA, CD45+/-,

CD5-/+, CD10+/-, BCL6 +/-, 3q27 region abnormalities involving BCL6 seen in 30% of cases, t(14;18)

involving BCL2 seen in 20-30% of cases, MYC rearrangement seen in 10% of cases

T Cell/Histiocytic-Rich Large B-Cell Lymphoma: PanB+, BCL6+, BCL2-/+, EMA -/+, background comprised

of CD3 and CD5 positive T-cells and CD68+ histiocytes

Primary DLBCL of the CNS: CD20+, CD22, CD79a, CD10-/+, BCL6+/-, IRF4/MUM1+/-, BCL2+/-, BCL6

translocations+/-, del 6q and gains of 12q, 22q, and 18q21 common

Primary Cutaneous DLBCL, Leg Type: sIG+, CD20+, CD79a+, CD10-, BCL2+, BCL6+, IRF4/MUM1+, FOX-

P1+; translocations involving MYC, BCL6, and IGH genes are common

EBV-Positive Diffuse Large B-Cell Lymphoma of the Elderly: CD20+/-, CD79a+/-, CD10-, IRF4/MUM1+/-,

BCL6-, LMP+, EBER+

DLBCL Associated With Chronic Inflammation: CD20+/-, CD79a+/-, CD138-/+, IRF4/MUM1-/+, CD30-/+, T-

cells markers-/+, LMP+/-, EBER+/-

Lymphomatoid Granulomatosis: CD20+, CD30+/-, CD79a-/+, CD15-, LMP+/-, EBER+.

Primary Mediastinal (Thymic) Large B-Cell Lymphoma: sIG-/+, PanB+, (especially CD20, CD79a),

CD45+/-, CD15-, CD30-/+ (weak), IRF4/MUM1 +/-, BCL2+/-, BCL6+/-, CD23+, MAL+; IGH and IGL gene

rearrangements

Intravascular Large B-Cell Lymphoma: Pan B+ (CD19, CD20, CD22, CD79a), CD5-/+, CD10-/+,

IRF4/MUM1+

ALK-Positive Large B-Cell Lymphoma: ALK+, CD138+, EMA+, VS38+, CD45-/+, CD4-/+,

CD57-/+, CD20-, CD79a-, CD3-, CD30-/+, IRF4/MUM1-/+, t(2;17)(p23;q23)+/-, t(2;5)(p23;35)-/+

Plasmablastic Lymphoma: CD38+, CD138+, Vs38c+, IRF4/MUM1+, CD79a+/-, EMA +/-, CD30+/-, CD45-/+,

CD20-/+, PAX5-/+, EBER+/-, EMA+/-, CD30+/-

Large B-Cell Lymphoma Arising in HHV8-Associated Multicentric Castleman Disease: CD20+/-, CD79a-,

CD38-/+, CD138-, EBER-, lambda light chain restricted

Primary Effusion Lymphoma: CD45+/-, CD30+/-, CD38+/-, CD138+/-, EMA+/-, CD19-, CD20-, CD79a-,

CD3-/+, BCL6-, HHV8/KSHV+, EBV+/-, IGH and IGL gene rearrangements

Burkitt Lymphoma: sIGM+, PanB+, CD5-, CD10+, BCL6+, CD38+, CD77+, CD43+, CD23-; Ki-67 (95-100%),

BCL2-; TdT-, IGH and IGL gene rearrangements, t(8;14)(q24;q32) and variants t(2;8)(p12;q24) and

t(8;22)(q24;q11); rearranged MYC gene; EBV common (95%) in endemic cases and infrequent (15-20%)

in sporadic cases, intermediate incidence (30-40%) in HIV-positive cases

B-Cell Lymphoma, Unclassifiable, With Features Intermediate Between Diffuse Large B-cell Lymphoma

and Burkitt Lymphoma: PanB+, CD10+, BCL6+, BCL2-/+, IRF4/MUM1-, Ki-67 (50-100%), 8q24/MYC

translocation (35-50%), BCL2 translocation (15%), and occasionally both translocations (so called double

hit lymphoma)

B-Cell Lymphoma, Unclassifiable, With Features Intermediate Between Diffuse Large B-cell Lymphoma

and Classical Hodgkin Lymphoma: CD45+/-, CD20+/-, CD79a+/-, CD30+/-, CD15+/-, PAX-5+/-, OCT-2+/-,

BOB.1+/-, CD10-, ALK-

Mature T-Cell and NK-Cell Neoplasms

T-Cell Prolymphocytic Leukemia: PanT+ (CD2, CD3, CD5, CD7), CD25-, CD4+/CD8->CD4+/CD8+>CD4-

/CD8-, TCL1+, TdT-, CD1a-; TCR gene rearrangements, 75% show inv 14 with breakpoints at q11 and q32,

10% have a reciprocal tandem translocation t(14;14)(q11;q32)

T-Cell Large Granular Lymphocytic Leukemia: PanT+ (CD2, CD3+, CD5+/-), CD7-, TCR+, CD4-, CD8+,

CD16+, CD56-, CD57+, CD25-, TIA1+, granzyme B+, TdT-; most cases show clonal TCR gene

rearrangements

Chronic Lymphoproliferative Disorder of NK Cells: sCD3-, cCD3+, CD16+, CD56 (weak), TIA1+, granzyme

B+, CD8+/-, CD2-/+, CD7-/+, CD57-/+, EBV-, karyotype is typically normal

Aggressive NK-Cell Leukemia: CD2+, sCD3-, cCD3+, CD56+, TIA+/-, CD16+/-, CD57-, Fas ligand+, EBV+,

del(6)(q21q25) and del(11q) can be seen

Systemic EBV-Positive T-Cell Lymphoproliferative Disease of Childhood: CD2+, CD3+, TIA+, CD8+ (if

associated with acute EBV infection), EBER+, CD56-, TCR gene rearrangements+

Hydroa Vacciniforme-like Lymphoma: Cytotoxic T-cell or less often CD56+ NK-cell phenotype, EBER+/-,

TCR gene rearrangement+

Adult T-Cell Leukemia/Lymphoma (HTLV1+): PanT+ (CD2+, CD3+, CD5+), CD7-, CD4+, CD8-, CD10+,

CD25+, TdT-; TCR gene rearrangements, clonally integrated HTLV1

Extranodal NK/T-Cell Lymphoma: CD2+, CD5-/+, CD7-/+, CD3-/+, granzyme B+, TIA1+, CD4-, CD8-,

CD56+/-, TdT-; usually no TCR or Ig gene rearrangements; usually EBV positive

Enteropathy-associated T-cell Lymphoma: CD3+, CD7+, CD4-, CD8-/+, CD103+, TdT-

Hepatosplenic T-cell Lymphoma: CD2+, CD3+, TCR gamma-delta+, TCR alpha-beta rarely +, CD5-,

CD7+, CD4-, CD8-/+, CD56+/-, CD25-; TCRG gene rearrangements +/-, variable TCRB gene

rearrangements -/+; isochromosome 7q and trisomy 8 common

Subcutaneous Panniculitis-like T-Cell Lymphoma: CD8+, granzyme B+, TIA1+, perforin+, TCR alpha/

beta +, CD4-, CD56-

Lymphomatoid Papulosis: CD4+, CD2-/+, CD3+, CD5-/+, TIA1+, granzyme B+/-, CD30+/-; TCR gene

rearrangements+/-

Primary Cutaneous Anaplastic Large-Cell Lymphoma: CD4+, TIA1+/-, granzyme B+/-, perforin+/-, CD30+,

CD2-/+, CD5-/+, CD3-/+, CLA+, ALK-, EMA-/+; TCR gene rearrangements+/-

Primary Cutaneous Gamma-Delta T-Cell Lymphoma: TCR gamma/delta+, CD2+, CD3+, CD5-, CD56+,

CD7+/-, CD4-, CD8-/+, Beta F1-

Primary Cutaneous CD8-positive Aggressive Epidermotropic Cytotoxic T-cell Lymphoma: CD3+, CD8+,

granzyme B+, perforin+, TIA1+, CD45RA+/-, CD2-/+, CD4-, CD5-, CD7-, EBV-, Beta F1+; TCR gene

rearrangements (alpha/beta)+

Primary Cutaneous CD4-Positive Small/Medium T-Cell Lymphoma: CD3+, CD4+, CD8-, CD30-, TCR gene

rearrangements+

Peripheral T-Cell Lymphoma, NOS: PanT variable (CD2+/-, CD3+/-, CD5-/+, CD7-/+), most cases CD4+,

some cases CD8+, a few cases are CD4-/CD8-, or CD4+/CD8+; TCR gene rearrangements+

Angioimmunoblastic T-Cell Lymphoma: PanT+ (often with variable loss of some PanT antigens), usually

CD4+, PD1+, CXCL13+; TCR gene rearrangements in 75%; IGH gene rearrangements in up to 30%, EBV

often positive in B-cells

Anaplastic Large Cell Lymphoma, ALK Positive: CD30+, ALK+, EMA+/-, CD3-/+, CD2+/-, CD4+/-, CD5+/-,

CD8-/+, CD43+/-, CD25+, CD45+/-, CD45RO+/-, TIA1+/-, granzyme+/-, perforin+/-, EBV-, TCR gene

rearrangements+/-, t(2;5)(p23;35) in 80% of cases, t(1;2)(q25;p23) in 10-15% of cases. Other various

translocations can also be seen.

Anaplastic Large Cell Lymphoma, ALK Negative: CD30+ (strong/intense staining),

CD2+/-, CD3+/-, CD5-/+, CD4+/-, CD8-/+, CD43+, TIA1+/-, granzyme B+/-, perforin +/-, ALK-, TCR gene

rearrangements+

Histiocytic and Dendritic Cell Neoplasms

Histiocytic Sarcoma: CD45+, CD163+, CD68+, lysozyme+, CD45RO+/-, HLA-DR+/-, CD4+/-, S100-/+,

CD1a-, CD21-, CD35-, CD13, CD33, myeloperoxidase-, lack IGH and TCR gene rearrangements

Langerhans Cell Histiocytosis: CD1a+, langerin+, S100+, vimentin+, CD68+, HLA-DR+, CD4-/+, CD30+,

most B- and T-cell markers are negative, there are no consistent cytogenetic abnormalities

Langerhans Cell Sarcoma: CD1a+, langerin+, S100+, vimentin+, CD68+, HLA-DR+, CD4-/+, CD30+, most

B- and T-cell markers are negative, there are no consistent cytogenetic abnormalities

Interdigitating Dendritic Cell Sarcoma: S100+, vimentin+, CD1a-, langerin-, CD45+/-, CD68+/-,

lysozyme+/-, p53+/-, CD21-, CD23-, CD35-, CD34-, CD30-, myeloperoxidase-, most B and T-cell markers

are negative, lack IGH and TCR gene rearrangements

Follicular Dendritic Cell Sarcoma: Clusterin+, CD21+, CD35+, CD23+, KiM4p+, desmoplakin+, vimentin+,

fascin+, EDGR+, HLA-DR+, CD1a-, myeloperoxidase-, lysozyme-, CD34-, CD30-, CD3-, CD79a-, lack IGH

and TCR gene rearrangements

Disseminated Juvenile Xanthogranuloma: vimentin+, CD14+, CD68+, CD163+, factor XIIIa+/-, fascin+/-,

S100-/+, CD1a-, langerin-, lack IGH and TCR gene rearrangements

F. Clinical Prognostic Factors and Indices

The specific histologic type of the lymphoid neoplasm, stage of disease, as well as the International

Prognostic Index (IPI score) are the main factors used to determine treatment in adults.13,21,28-33

The 5

pretreatment characteristics that have been shown to be independently statistically significant are: age

in years (≤60 versus >60); tumor stage I or II (localized) versus III or IV (advanced); number of extranodal

sites of involvement (0 or 1 versus >1); patient’s performance status (0 or 1 versus 2 to 4); and serum LDH

(normal versus abnormal). Based on the number of risk factors, patients can be assigned to 1 of 4 risks

groups: low (0 or 1), low intermediate (2), high intermediate (3), or high (4 or 5). Patients stratified by the

number of risk factors were found to have very different outcomes with regard to complete response

(CR), relapse-free survival (RFS), and overall survival (OS).13

Studies show that low-risk patients had an

87% CR rate and an OS rate of 73% at 5 years compared to high-risk patients who had a 44% CR rate

and a 26% 5-year overall survival rate.13

A revised IPI (R-IPI) has been proposed for patients with diffuse

large B-cell lymphoma who are treated with rituximab plus CHOP chemotherapy.34

In pediatric cases,

there is no equivalent of the IPI, and prognosis is based on stage and type of lymphoma.16

A separate prognostic index has become accepted for follicular lymphoma. The Follicular Lymphoma

International Prognostic Index (FLIPI) appears to provide greater discrimination and stratification among

patients with follicular lymphoma.35

It evaluates 5 adverse prognostic risk factors including age (>60

years versus ≤60 years), Ann Arbor stage (III to IV versus I to II), hemoglobin level (<120 g/L versus ≥120

g/L), number of nodal areas (>4 versus ≤4) and serum LDH level (above normal level versus normal or

below). Patients are stratified into 3 risk groups: low risk (0-1 adverse factors), intermediate (2 adverse

factors) and poor risk (≥3 adverse factors).

Prognostic indices are also under development in other lymphoid neoplasms such as mantle cell

lymphoma and T-cell lymphomas.

Although not always provided to the pathologist by the physician submitting the specimen, certain

specific clinical findings are known to be of prognostic value in all stages of NHL. In particular, systemic

symptoms of fever (greater than 38°C), unexplained weight loss (more than 10% body weight) in the

6 months before diagnosis, and drenching night sweats are used to define 2 categories for each stage

of NHL: A (symptoms absent) and B (symptoms present). The presence of B symptoms is known to

correlate with extent of disease (stage and tumor bulk), but symptoms also have been shown to have

prognostic significance for cause-specific survival that is independent of stage.6,28-33,36

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19

Protocol for the Examination of Specimens from Patients with Hodgkin Lymphoma Protocol applies to Hodgkin lymphoma involving any site. #

Based on AJCC/UICC TNM, 7th Edition Protocol web posting date: October 2009

Procedures

Biopsy

Resection of Lymph Node(s) or Other Organ(s)

Authors

Jerry W. Hussong, MD, DDS, FCAP*


Daniel A. Arber, MD

Stanford University School of Medicine, Stanford, California Kyle T. Bradley MD, MS, FCAP

Emory University Hospital, Atlanta, Georgia


Yellowstone Pathology Institute Inc, Billings, Montana Chung-Che Chang, MD, PhD, FCAP The Methodist Hospital, Houston, Texas Monica E. de Baca, MD, FCAP Physicians Laboratory Ltd, Sioux Falls, South Dakota David W. Ellis, MBBS, FRCPA Flinders Medical Centre, Bedford Park, South Australia Kathryn Foucar, MD, FCAP University of New Mexico, Albuquerque, New Mexico Eric D. Hsi, MD, FCAP Cleveland Clinic Foundation, Cleveland, Ohio Elaine S. Jaffe, MD National Cancer Institute, Bethesda, Maryland


Cedars-Sinai Medical Center, Los Angeles, California Stephen P. McClure, MD Presbyterian Pathology Group, Charlotte, North Carolina L. Jeffrey Medeiros, MD, FCAP MD Anderson Cancer Center, Houston, Texas


University of Utah Health Sciences Center, Salt Lake City, Utah For the Members of the Cancer Committee, College of American Pathologists *denotes the primary and senior author. All other contributing authors are listed alphabetically.

© 2009 College of American Pathologists (CAP). All rights reserved.

A. Specimen Any number of specimen types may be submitted in the evaluation of Hodgkin lymphoma. Lymph nodes, mediastinal masses, bone marrow, spleen, lung, and liver are among the most common. Specimens submitted with a suspected diagnosis of Hodgkin lymphoma require special handling in order to optimize the diagnosis. Often, lymph node specimens are submitted

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where the differential diagnosis includes both Hodgkin and non-Hodgkin lymphomas, and, if possible, tissue should be obtained for possible molecular and other ancillary studies, which are often necessary for the diagnosis of non-Hodgkin lymphomas.1,2 Most flow cytometry, molecular, and cytogenetic studies will not aid in the diagnosis of Hodgkin lymphoma. Immunophenotyping by immunohistochemical staining is necessary in the initial diagnosis of nearly all cases of Hodgkin lymphoma. Because of this, well-fixed sections are of paramount importance. The guidelines detailed below are suggested for specimen handling in cases of suspected Hodgkin lymphoma.

Tissue should be received fresh. Unsectioned lymph nodes should not be immersed in fixative, and care should be taken to make thin (2 mm) slices perpendicular to the long axis of the node to ensure optimal penetration of fixative.

The fresh specimen size, color, and consistency should be recorded, as should the presence or absence of any visible nodularity, hemorrhage, or necrosis.

Touch imprints may be made from the freshly cut surface, and the imprints fixed in alcohol or air dried. Unstained air-dried imprints can be used for fluorescence in situ hybridization (FISH) or other studies if necessary.

For microbiology studies: submit a fresh portion of the lymph node (or other specimen type) sterilely in appropriate medium.

Flow cytometry immunophenotyping is not routinely used in the diagnosis of Hodgkin lymphoma, but if the differential diagnosis includes non-Hodgkin lymphoma, a fresh portion of the specimen should be submitted in appropriate transport medium such as RPMI.

Fixation (record fixative[s] used for individual slices of the specimen): o Estimated time from excision to fixation should be noted, if possible, as this may impact

preservation or recovery of certain analytes such as RNA and phosphoproteins in fixed tissues.

o Zinc formalin or B+ produces superior cytologic detail but is not suitable for DNA extraction and may impair some immunostains (eg, CD30). B+ also has the additional limitation of requiring proper hazardous materials disposal.

o Formalin fixation is preferable when the tissue sample is limited, as it is most suitable for immunohistochemistry as well as many other ancillary tests such as molecular/genetic studies and in-situ hybridization.

o Over-fixation (ie, more than 24 hours in formalin, more than 4 hours in zinc formalin or B+) should be avoided for optimal immunophenotypic reactivity.

B. Tumor Site Hodgkin lymphomas are nearly always nodal based with cervical lymph nodes more commonly involved. It can also frequently be seen involving mediastinal, axillary, and paraaortic lymph nodes. Extranodal Hodgkin lymphoma can rarely be seen. The anatomic distribution of Hodgkin lymphoma, however, varies depending on the histologic type.3

C. Histologic Type This protocol recommends assigning histologic type based on the World Health Organization (WHO) classification of lymphoid neoplasms.4 It was originally published in 2001 and more recently revised and updated in 2008.4,5 This classification encompasses both Hodgkin and non-Hodgkin lymphomas and allows distinction of individual lymphoid neoplasms based upon morphologic, immunophenotypic, cytogenetic, and clinical features. While histologic examination typically is thought to be the gold standard, the majority of Hodgkin lymphomas will require immunohistochemical staining, especially at the time of initial diagnoses.4-9 In addition, while Hodgkin lymphomas are currently divided into nodular lymphocyte predominant Hodgkin lymphoma and classical Hodgkin lymphomas (including nodular sclerosis, mixed cellularity,

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lymphocyte-rich, and lymphocyte-depleted subtypes), it should be recognized that classical Hodgkin lymphomas may not represent a single disease. In addition, there is overlap between some cases of Hodgkin lymphoma and non-Hodgkin lymphoma, particularly diffuse large B-cell lymphomas (so-called gray zone lymphomas).4,10

D. Pathologic Extent of Tumor (Stage) The TNM classification is not used for staging Hodgkin lymphomas because the site of origin of the tumor is often unclear and there is no way to differentiate among T, N, and M. The Cotswold revision of the Ann Arbor staging classification is used for Hodgkin lymphoma.11,12 It was originally published over 30 years ago. Pathologic staging depends on the biopsy of multiple lymph nodes on both sides of the diaphragm, splenectomy, wedge liver biopsy, and bone marrow biopsy to assess distribution of disease. Currently, staging for Hodgkin lymphoma is more commonly clinical than pathologic. Clinical staging generally involves a combination of clinical, radiologic, and surgical data. Physical examination, laboratory tests, imaging studies (eg, computed tomography [CT] scans, magnetic resonance imaging [MRI] studies, and positron emission tomography [PET]), biopsy (to determine diagnosis, histologic type, and extent of disease), and bone marrow examination are often required. Correct diagnosis and staging are the key factors in providing appropriate treatment.13-15

Cotswold Revision of the Ann Arbor Staging Classification of Hodgkin Lymphomas13,14 Stage I Involvement of a single lymph node region (I), or lymphoid structure (eg, spleen,

thymus, Waldeyer’s ring).# Stage II Involvement of 2 or more lymph node regions on the same side of the diaphragm

(II) (the mediastinum is considered a single site). ## Stage III Involvement of lymph node regions on both sides of the diaphragm (III) which

may be accompanied by extralymphatic extension in association with lymph node involvement (IIIE) or splenic involvement (IIIS).

Stage IV Involvement of extranodal site(s) beyond those designated E. # Multifocal involvement of a single extralymphatic organ is classified as stage IE and not stage IV. ## The number of lymph node regions involved may be indicated by a subscript: eg, II3.

E designates involvement of a single extranodal site or contiguous or proximal known nodal site of disease.

E. Immunophenotyping Immunophenotyping by flow cytometry and molecular testing by polymerase chain reaction (PCR) are currently not typically used or are not necessary for the diagnosis of Hodgkin lymphoma. Immunophenotyping using immunohistochemistry is necessary for the initial diagnosis of nearly all cases of Hodgkin lymphoma. It requires well-fixed tissue sections for optimal immunohistochemical staining and interpretation.

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Immunophenotypes1,4-8

The following is to be used as a guideline for the more common immunophenotype for each subtype of Hodgkin lymphoma. It is however, not entirely comprehensive and individual cases may vary somewhat in their immunophenotypic profile. Nodular lymphocyte predominant Hodgkin lymphoma: Lymphocyte predominant cells (LP cells; previously called L&H cells) are CD20+, CD79a+, PAX5+, CD45+, BCL6+, OCT-2+, BOB.1+, EMA +/-, CD15-, CD30-, CD43-, EBER-. Nodular sclerosis classical Hodgkin lymphoma: Classical Hodgkin/Reed-Sternberg cells are CD30+, CD15+/-, CD45-, PAX5+/-, CD20-/+, CD79a-/+, EBER-/+, OCT-2-/+, BOB.1-/+, EMA- Mixed cellularity classical Hodgkin lymphoma: Classical Hodgkin/Reed-Sternberg cells are CD30+, CD15+/-, CD45-, PAX5+/-, CD20-/+, CD79a-/+, EBER+/-, OCT-2-/+, BOB.1-/+, EMA- Lymphocyte-rich classical Hodgkin lymphoma: Classical Hodgkin/Reed-Sternberg cells are CD30+, CD15+/-, CD45-, PAX5+/-, CD20-/+, CD79a-/+, EBER-/+, OCT-2-/+, BOB.1-/+, EMA- Lymphocyte-depleted classical Hodgkin lymphoma: Classical Hodgkin/Reed-Sternberg cells are CD30+, CD15+/-, CD45-, PAX5+/-, CD20-/+, CD79a-/+, EBER+/-, OCT-2-/+, BOB.1-/+, EMA-

F. Clinical Prognostic Factors and Indices The International Prognostic Score (IPS) was developed for Hodgkin lymphoma to predict outcome based on the following adverse factors: serum albumin <4g/dL, hemoglobin concentration <10.5 g/dL, male sex, age ≥45 years, stage IV disease, white blood cell count ≥15,000/mm3, and lymphopenia <600/mm3 or <8%. The rate of freedom from progression by risk category is: 0 factors 84%, 1 factor 77%, 2 factors 67%, 3 factors 60%, 4 factors 51%, and 5 or more factors 42%.13 Although not always provided to the pathologist by the physician submitting the specimen, certain clinical findings are known to be of prognostic value in all stages of Hodgkin and non-

Hodgkin lymphoma. In particular, systemic symptoms of fever (greater than 38C), unexplained weight loss (more than 10% body weight) in the 6 months before diagnosis, and drenching night sweats are used to define 2 categories for each stage of lymphoma: A (symptoms absent) and B (symptoms present). The presence of B symptoms is known to correlate with extent of disease (stage and tumor bulk), but symptoms also have been shown to have prognostic significance for cause-specific survival that is independent of stage.13 In addition to the IPS, other prognostic factors, including HIV status, Bcl-2 expression, and pretreatment interleukin-10 serum levels, may be important. 18-21

References 1. Knowles D, ed. Neoplastic Hematopathology. Philadelphia, PA: Lippincott Williams and

Wilkins; 2001. 2. Mills S, ed. Histology for Pathologists. Philadelphia, PA: Lippincott Williams and Wilkins;

2007.

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3. Shimabukuro-Vornhagen A, Haverkamp H, Engert A, et al. Lymphocyte-rich classical Hodgkin’s lymphoma: clinical presentation and treatment outcome in 100 patients treated within German Hodgkin’s Study Group trials. J Clin Oncol. 2005; 23(24):5739-5745.

4. Swerdlow S, Campo E, Harris N, Jaffe E, Pilero S, Stein H, Thiele J, Vardiman J, eds. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. Geneva, Switzerland: WHO Press; 2008.

5. Jaffe ES, Harris NL, Stein H, Vardiman JW, eds. Pathology and Genetics of Tumours of Haematopoietic and Lymphoid Tissues. Lyon, France: IARC Press; 2001. World Health Organization Classification of Tumours, Vol. 3.

6. Hsi E, Goldblum J, eds. Hematopathology. Philadelphia, PA: Churchill Livingstone Elsevier; 2007.

7. Zukerberg L, Collins AB, Ferry JA, Harris NL. Coexpression of CD15 and CD20 by Reed-Sternberg cells in Hodgkin’s disease. Am J Pathol. 1991; 139(3):475-483.

8. Jaffe E, Banks P, Nathwani B, et al. Recommendations for the reporting of lymphoid neoplasms: a report from the Association of Directors of Anatomic and Surgical Pathology. Mod Pathol. 2004; 17(1):131-135.

9. Stein H, Marafioti T, Foss H, et al. Down-regulation of BOB.1/OBF.1 and Oct2 in classical Hodgkin disease but not in lymphocyte predominant Hodgkin disease correlates with immunoglobulin transcription. Blood. 2001; 97(2):496-501.

10. Mani H, Jaffe E. Hodgkin lymphoma: an update on its biology with new insights into classification. Clin Lymphoma Myeloma. 2009; 9(3):206-216.

11. Carbone P, Kaplan H, Musshoff K, et al. Report of the Committee on Hodgkin’s Disease Staging Classification. Cancer Res. 1971; 31(11):1860-1861.

12. Lister T, Crowther D, Sutcliffe S, et al. Report of a committee convened to discuss the evaluation and staging of patient’s with Hodgkin’s disease: Cotswolds meeting. J Clin Oncol. 1989;7(11):1630-1636.

13. Lymphoid neoplasms. In: Edge SB, Byrd DR, Carducci MA, Compton CC, eds. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer; 2009.

14. Sobin LH, Gospodarowicz M, Wittekind Ch, eds. UICC TNM Classification of Malignant Tumours. 7th ed. New York, NY: Wiley-Liss; in press.

15. Kwee T, Kwee R, Nievelstein R. Imaging in staging malignant lymphoma: a systematic review. Blood. 2008; 111(2):504-516.

16. Hasenclever D, Diehl V. A prognostic score for advanced Hodgkin’s disease: International Prognostic Factors Project on Advanced Hodgkin’s Disease. N Engl J Med. 1998; 339(21):1506-1514.

17. Allemani C, Sant M, De Angelis R, et al. Hodgkin disease survival in Europe and the U.S.: prognostic significance of morphologic groups. Cancer. 2006; 107(2):352-360.

18. Vassilakopoulos T, Angelopoulou M, Siakantaris M, et al. Prognostic factors in advanced stage Hodgkin’s lymphoma: the significance of the number of involved anatomic sites. Eur J Haematol. 2001; 67(5-6):279-288.

19. Sup J, Alemany C, Pohlman B, et al. Expression of bcl-2 in classical Hodgkin’s lymphoma: an independent predictor of poor outcome. J Clin Oncol. 2005;23(16):3773-3779.

20. Rautert R, Schinkothe T, Franklin J, et al. Elevated pretreatment interleukin-10 serum level is an International Prognostic Score (IPS)-independent risk factor for early treatment failure in advanced stage Hodgkin lymphoma. Leuk Lymphoma. 2008; 49(11):2091-2098.

21. Rassidakis G, Medeiros LJ, Vassilakopoulos T, et al. Bcl-2 expression in Hodgkin and Reed-Sternberg cells of classical Hodgkin lymphoma predicts a poorer prognosis in patients treated with AVBD or equivalent regimens. Blood. 2002; 100(12):3935-3941.

Immunohistochemistry

Immunostains/In-Situ Hybridization Laboratory and Ordering Information

Immunostain Turnaround Time

IHC Routine runs: All orders received before 10:00am should be sent out the same day by 5:30pm (i.e. Monday through Friday) provided the laboratory has the block (or slides). There are a few stains (e.g. EBER, SV40, TdT, and antibody reactions on frozens) that require longer incubations and these may be delayed by one day. Orders received after 10:00am will be out the following morning by the 8:30am courier.

The Immunohistochemistry Laboratory is located at the CLB and personnel can be reached at 647-7663.

A list of the antibodies we use most frequently and a complete list with codes are included in the manual.

ORDERING OF IMMUNOSTAIN PANELS

It is strongly recommended that the Audix voicemail (412-803-3273) is utilized when ordering stains in order to facilitate delivery to Hematopathology.

If ordering after hours, the stain panels must now be ordered as Stain/Process Group Protocols (see separate list).

(Unlike a Histology Protocol, a Stain/Process Group Protocol will not write over stains that have been previously ordered on the same part)

To order one of the protocols:

1. If you are ordering the panel using the “Accession Entry/Edit” or “Histology Entry/Edit” activities:

Go to the Histology tab.

Select the part (and/or block) on which you wish to order the panel.

Then click on the “Run Stain/Process Group…” button.

Enter the abbreviation for the Protocol in the “Select Protocol” field on the “Run Stain/Process Group Protocol” pop up window.

Hit tab (on your keyboard). Then hit Enter (on your keyboard) or click the OK button in the “Run Stain/Process Group Protocol” pop up window.

2. If you are ordering the panel using the “Stain/Process and Block Edit” activity: Select the part (and/or block) on which you wish to order the panel.

Click on the “Add Stain/Process…” button.

Clinical on the “Run Stain/Process Group…” button.

Enter the abbreviation for the Protocol in the “Select Protocol” field on the “Run Stain/Process Group Protocol” pop up window.

Hit tab (on your keyboard). Then hit Enter (on your keyboard) or click the OK button in the “Run Stain/Process Group Protocol” pop up window.

In the comment field enter” Please deliver to Hematopathology” – otherwise the slides may end up in your mailbox!! If you have any questions, please contact AP User Support via e-mail or at 647-9170

ORDERING EXPERIMENTAL STAINS (ANTIBODIES NOT YET IN COMPUTER) If being done in the routine immunohistology laboratory, order under ABNKNC. Specify desired stain in the comment of ABNKNC. If being done in the in situ laboratory order 2 blanks (IBNKNC) and write in comment to sent to insitu laboratory for_________.

Reporting of Immunostains/in-situ hybridization

The template should always be utilized and follows the general microscopic description.

Stains Frequently Used In Hematopathology: Codes and Reactivities Here’s a list of markers that are used commonly on the Lymph Node Service and their secret Client Server code-names. See also the Hematopathology worksheet since its best to order via panels.

Antigen / Marker

C/S Code-name

Cell-type/s Comment

CD1a ACD1 Thymocytes, Langerhans Cells

CD2 ACD2 T-cells, NK-cells


CD4 ACD4 T-cells, Macrophage

CD5 ACD5 T-cells, SLL/CLL & Mantle cell lymphoma, B-cell subset



CD10 (CALLA)

ACD10 Lymphoblasts, Follicular center cells, Granulocytes, Some epithelial cells/neoplasms, Follicular T-cells

CXCL-13 ACXCL13 Follicular T helper cells

PD-1 APDT Follicular T helper cells

CD15 (Leu-M1)

ALEUM1 R-S cells, CMV-infected cells, Some carcinomas

CD20 (L26) AL26 B-cells

CD21 ACD21 Follicular dendritic cells, Some B-cells

CD22 ACD22 B-cells

CD23 ACD23 Follicular dendritic cells, SLL/CLL, Normal mantle cells

CD30 (Ki-1/Ber-H2)

ACD30 R-S cells, Activated T & B-cells, Some lymphomas, Embryonal carcinoma

CD31 ACD31 Endothelium

CD33 ACD33 Myeloid

CD34 ACD34 Blasts, Endothelium, Various mesenchymal neoplasms

CD43 ACD43 T-cells, Myeloid cells, B-cell subset, SLL/CLL, Mantle cell lymphoma, Other B-cell lymphomas, Not most follicular lymphomas

CD45 (LCA) ALCA All leukocytes

CD45RA (4KB5)

ACD45R B-cells, Plasmacytoid dendulic cells

CD45RO (UCHL-1)

AUCHL1 T-cells, Macrophages

CD56 ACD56 NK-cells, “NK-like” T-cells; Some malignant myeloblasts, lymphoblasts & plasma cells (multiple myeloma)

CD57 (Leu 7)

ALEU7 NK-cells, Neural tissues, T-cell subset in follicles

CD61 ACD61B Megakaryocytes

CD68 ACD68 Monocyte/Macrophage, Many Melanomas!

CD79a ACD79 B-cells

CD99 AEWING Blasts, Ewing Sarcoma

CD138 ACD138 Plasma cells, R-S cells, Some epithelial cells

Alk-1 AALK Anaplastic large cell lymphoma (systemic)

Nuclear or nuclear and cytoplasmic stain.

TIA-1 ATIA T-cells & NK-cells with cytolytic granules

Granular cytoplasmic stain

Granzyme B AGRANZ Cytotoxic T-cells and NK cells

Clusterin ACLUST Positive staining in anaplastic large cell lymphomas

Bcl-2 ABCL2 Many normal cells but NOT NORMAL germinal center cells; Majority of low grade follicular lymphomas, fewer intermediate grade ones; Many other lymphomas

Cytoplasmic stain (actually mitochondrial)

Cyclin-D1 (bcl-1)

ACYCLD Mantle cell lymphoma, Some multiple myelomas, Epithelial cell/neoplasms

Nuclear stain (Don’t call cytoplasmic stain positive)

Bcl-6 ABCL6 Germinal center B-cells (follicular center cells); Many diffuse large B-cell lymphomas

Nuclear stain

Ki-67 (MIB-1)

AKI67 Proliferation marker (G1/S/G2/M phases)

Nuclear stain

TdT(Terminal-deoxynucleotidyl Transferase)

ATDT Lymphoblasts; Sometimes myeloblasts (<20%)

MPO (Myeloperoxidase)

AMPO Myeloid cells

Tryptase ATRYP Mast cells

Neutrophil Elastase

ANE Neutrophils and their precursors

CD123 ACD123 Plasmacytoid dendritic cells, some AML, HCL, basophils (at least by flow cytometry)

Used for blastic plasmacytic dendritic cell neoplasms (this is WHO term), mature PDC in CD, necrot. lymphad, other

Kappa light chain

AKAPPA Ig light chain kappa

Lambda light chain

ALAMDA Ig light chain lambda

J chain AJ J chain of IgA & IgM

Beta-F1 ABF1 Beta-F1 T-cell receptor chain on T-cells

Glycophorin-A

AGLYP RBC’s and their precursors

PAX5 APAX5 B-cells (nuclear stain)

EBV EBER-ISH

IEBER Epstein-Barr Virus Encoded mRNA (in situ hybridization)

Order under Run Stain/Process Group

Kappa mRNA-ISH

IRKAP Ig light chain kappa mRNA (in situ hybridization)


p27 AP27 Pos in indolent B-cell lymphomas but not MCL

Lambda mRNA-ISH

IRLAM Ig light chain lambda mRNA (in situ hybridization)


Kappa/Lambda double stain

IKPLM Kappa is black /Lambda is red-orange (antibody stain performed in in-situ hybridization lab)


Bartonella henselae stain

CABART Bartonella henselae

Complete Immunohistochemical Stain Abbreviations/Codes See online library for detailed information re: clones, etc https://www.medialabinc.net/lms/student/st_login.aspx?brandid=2 (See Hematopathology Dept for Login)

Antibody Test Code

Actin - Smooth muscle (SMA) AACTIN

Actin All Muscle AMA

Adenovirus Adenovirus

Adhalin Adhalin

Adrenocorticotropic Hormone ACTH

AE1 AE1

AE1/3 AE1/3

AE3 AE3

ALK-LUNG ALK-LUNG

Alpha 1 Antitrypsin AAT

Alpha-Fetoprotein AFP

Alzheimer beta Amyloid A4G8

Anaplastic Lymphoma Kinase AALK1

androgen receptor AAR

Annexin-1 Annexin-1

APP APP

B72.3/TAG Tumor Glycoprotein ATAG

Bartonella Henselae Bhenselae

Bcl-2 Oncoprotein ABCL2

BCL6 ABCL6

BerEP4 ABEREP4

Beta Catenin ABCATN

BetaF1 T-cell Receptor ABF1

BHCG ABHCG

BK Virus ABKV

BOB1 ABOB1

C1Q Complement AC1Q

C4d AC4D

C5B-9 Membrane Complex APMAC

https://www.medialabinc.net/lms/student/st_login.aspx?brandid=2

CA125 ACA125

CA19.9 YCA199

CA9 ACA9

Calcitonin ACALCI

Caldesmon ACALDES

Calponin ACALP

Calretinin ACALRET

CAM 5.2 CAM 5.2

CD10 (CALLA) ACD10

CD117 C-KIT CD117

CD138 ACD138

CD15 ACD15

CD1a ACD1A

CD2 ACD2

CD20 - L26 CD20

CD21 CD21

CD22 CD22

CD23 CD23

CD25 INTERLEUKIN2 ACD25

CD3 CD3

CD30 CD30

CD31 ACD31

CD33 CD33

CD34 CD34

CD4 CD4

CD4 Frozen CD4f

CD43 CD43

CD45RA CD45RA

CD5 CD5

CD56 CD56

CD57 CD57

CD61 CD61

CD68 CD68

CD7 CD7

CD79a CD79a

CD8 CD8

CD99 - Ewing CD99

CDX2 CDX2

CEA ACEA

CEA-M CEAM

Chromogranin ACHROMO

CITED-1 ACITED-1

CKIT - CD117 ACKIT

CLUSTERIN ACLUST

c-MYC MYC

c-MET c-MET (SP44)

COLLAGEN IV ACOL4

CRP CRP

CXCL13 CXCL 13

Cyclin D1 - BCL-1 ACYCLD1

Cytokeratin - Pan Keratin APANKLAM

Cytokeratin 19 ACK19

Cytokeratin 20 - CK20 ACK20

Cytokeratin 5 CK5

Cytokeratin 5/6 - CK5/6 ACK5/6

Cytokeratin 7 - CK7 ACK7

Cytokeratin AE1/AE3 - CK AE1/3 AE1/3

Cytomegalovirus ACMV

D2-40 AD240

Desmin ADESMIN

DOG1 DOG1

Dysferlin ADYSF

Dystrophin1 DYS1

Dystrophin2 DYS2

E-Cadherin ECAD

EGFR AEGFR

EMA AEMA

Epstein Barr virus - EBV AEBV

ER AER

ERCC1 AERCC1

ERG ERG

Ewing sarcoma - CD99 AEWING

Factor 8 - vonWillebrand AVWF

Factor XIIIa AXIII

Fibrinogen FIBRINOGEN

FLI1 FLI-1

Fmac AFMAC

Follicle Stim. Hormone FSH

Galectin-3 Galectin-3

Gastrin Gastrin

GATA-3 GATA3

GCDFP15 AGCDFP

Glial Fibrillary Acidic Protein - GFAP AGFAP

Glucagon GLUC

Glut-1 AGLUT1

Glutamine Synthetase AGLUTSYNTH

Glycophorin A AGLYP

Glypican-3 GPC-3

Granzyme B AGRANZB

Growth Hormone AGH

H. pylori HPYL

HBME-1 AHBME

Hepatitis B Core AHBCOR

Hepatitis B Surface AHBS

HepPar 1 Hepatocytes AHEPAR

Her-2/neu c-erb ANEU

Herpes Simplex Virus I & II AHSV12

HHV8 HHV8ip

HMB45 Melanoma AHMB45

HPV Papilloma Virus AHPV

HSP70 AHSP70

IBA1 IBA1

IDH1 IDH1

IgA AIGA

IgD AIGD

IgG AIGG4

IgG4 AIGG4

IgM AIGM

IMP3 IMP3

Inhibin Alpha AINHIB

Insulin AINSU

Interleukin2 - CD25 ACD25

J chain of IgA+IgM AJ

Kappa Light Chain AKAPPA

KI67 Proliferating Cells Ki67

LAM/PANK APANKLAM

Lambda BM LAMBDABM

Lambda Light Chain ALAMBDA

Laminin ALAM

LCA, CD45 Monoclonal LCAMH

LEF-1 LEF-1

Leu M1 - CD15 ACD15

Lutenizing Hormone ALH

Lysozyme ALYSO

LYVE1 LYVE1 BROWN

Mac 387 macrophage AMC387

Mammaglobin AMAMA

MCPyV MCPYV

Melan A/Melanoma MELANA

Merosin Frozen

MHC1 AMHC1

MITF AMITFD

Mitochondrial MITOC

MLH1 Homolog MLH1

MOC-31 MOC31

MSH2 MSH

MSH6 AMSH6

MUC-1 AMUC1

MUC-2 AMUC2

MUC-4 AMUC4

MUC-5AC AMUC5AC

MUC-6 AMUC6

MUM-1 AMUM1

Myelin Basic Protein (MBP) MBP

Myeloperoxidase AMPO

Myogenin AMYOGN

Myoglobin AMYO

Myosin Heavy Chain ASMYOS

Napsin A ANAPA

NEUN ANEUNUC

Neurofilament ANFIL

Neuron Specific Enolase ANSE

Neutrophil Elastase ANEUNUC

NKIC3 melanoma ANKIC3

NKX3.1 N/a

OCT_2 Oct_2

OCT3/4 OCT3/4

OPD4 (CD45RO) AOPD4

P16 AP16

P21, WAF1 AP21

P27 AP27

P40 n/a

P501S P501S

P504S AP504S

P53 Tumor Suppressor Protein AP53

P63 Tumor Suppressor Protein AP63

P75 NGF P75

P903 AP903

Pan Cytokeratin CKPAN

Pancreatic Polypeptide APP

PANK (for PANK/LAM DS) APANKLAM

Parathyroid Hormone APTH

Parvalbumin APARV1

Parvovirus APARVO

Pax-5, B-cell Specific Activator Protein APAX5

PAX-8 PAX8

PD1 PD1

PGP 9.5 Neuroendocrine APFP

PIN4 APIN4

PLAP PLAP

PMAC P5B PMAC

PMS2 PMS2

Pneumocystis carinii APCAR

PREA ATTR ATTR

Progesterone Receptor APR

Prolactin APRO

Prostate Specific Acid Phosphatase APAP

Prostatic Specific Antigen APSA

PSTAT3 APSTAT

Renal Cell Carcinoma ARCC

S100 AS100

Serotonin ASERO

SDHB SDHB

Smoothelin SMOOTHELIN

Somatostatin ASOMAT

SOX11 SOX11

Surfactant Protein A ASPA

Synaptophysin ASYNP

TAG-72 ATAG

TAU TAU

TCL-1A TCL-1A

Terminal Deoxynucleotide Transferase - TdT TDT

TDP43 TDP-43

TFE3 TFE3

Thrombomodulin ATHROMBO

Thyroglobulin ATHYRO

TIA1 granzyme ATIA1

Toxoplasma ATOXO

Treponema pallidum ATREP

Trypsin TRYP

TRYPTASE TRYPTASE

TSH ATSH

TTF-1 TTF1

Tyrosinase ATYROS

Ubiquitin AUBQ

UCHL1 CD45RO AUCHL1

UP III AUPIII

Varicella zoster AVZV

Vimentin AVIMEN

WT-1 AMESO

CODES FOR DOUBLE LABELING

ICKDE AE1/AE3 and desmin ICKAC AE1/AE3 and actin (HHF35) ICKMI AE1/AE3 and MIB-1 In all cases cytokeratin staining will be red (AEC) and the second antibody will be black (Nickel enhanced DAB). IKPLM Kappa (black) and Lambda (red) IBT T-cell (CD3-black) and B-cell (L26/CD20-red)

IN-SITU HYBRIDIZATION PROBES AVAILABLE

Insitu (Brightfield)

iADV Adenovirus iBKV BKV insitu iCMV CMV insitu iEBER EBER probe for EBV mRNA (Ventana) iHPV HPV probe panel (manual method) i1618 HPV 16,18,31,33,35,39,45,51,52,56,58,66 subtype (high)(Ventana) i611 HPV 6+11 subtype (low) (Ventana) iHSV HSV probe iJCV JC virus probe iRLAM mRNA for Lambda light chain restriction (Ventana) iRKAP mRNA for Kappa chain restriction (Ventana)

IHC testing in ISH Laboratory

aMIT Mitochondrial antibody aPALABU Kidney aBAPP Neuropathology

IHC/ISH Reporting Templates

PHS/B:______________________ Name:______________________ PARAFFIN SECTION IMMUNOHISTOCHEMISTRY/IN-SITU HYBRIDIZATION

In order to characterize ___________________, paraffin section immunohistologic/in-situ hybridization studies were performed on ___________________. The following results were found:

Antigen/Antibody Usual Reactivity Result

anti-kappa B-cell subset

kappa mRNA-ISH B-cell subset

anti-lambda B-cell subset

lambda mRNA-ISH B-cell subset

anti-IgG B-cell subset

anti-IgG4 B-cell subset

anti-IgA B-cell subset

anti-IgM B-cell subset

anti-IgD B-cell subset

CD20/L26 B-cells

CD19 B-cells

CD22 B-cells

CD79a B-cells

PAX 5 B-cells

CD21 Follicular dendritic cells

CD35 Follicular dendritic cells

CD23 B-cell subset, follicular dendritic cells

CD138 Plasma cells, other

CD38 Activated cells, plasma cells

J chain Plasma cells, other

BCL2 Lymphocyte subset, other

BCL2 E17 Lymphocyte subset, other

MYC MYC protein

BCL6 Follicular center cells, other

CD10 B-cell subset

IRF4/MUM-1 B-cell subset

Cyclin D1 Mantle cell lymphoma, other

SOX-11 Mantle cell lymphoma, other

P27 Lymphoid subset

LEF-1/TCF-1 CLL/SLL, T-cells, other

Annexin A1 Hairy cell leukemia, myeloid, T cell subset

TdT Lymphoblasts, some myeloblasts

CD45/LCA Leukocytes

CD15/Leu M1 Reed-Sternberg cells, myeloid

CD30/Ber H2 RS cells, activated lymphs

EMA Epithelium, lymphocyte subset

OCT-2 B-cells, other

Bob.1 B-cells, other

ALK-1 Anaplastic large cell lymphoma kinase

Clusterin ALCL, other

CD1a Thymocytes, Langerhans-type cells

CD2 T and NK-cells

CD3 T and NK-cells

CD4 T-helper/inducer cells

CD5 T-cells, B-cell subset

CD7 T and NK-cells

CD8 T-cytotoxic/suppressor cells

CD43/Leu 22 T-cells, some B-cells, myeloid

CD279/PD-1 T-follicular helper cells, other

CXCL13 T-follicular helper cells, other

Beta-F1 TCR-beta chain

Gamma TCR TCR gamma

CD56 T-cell subset and NK-cells

CD57/Leu 7 T and NK cell subsets

TIA1 Cytotoxic cells

Granzyme B Activated cytotoxic cells

CD25 Activated lymph, other

CD68/PGM-1 Myeloid, macrophages

CD123 Plasmacytoid dendritic cells, Hairy cell leukemia, other

TCL-1 Plasmacytoid dendritic cells, T-PLL, B-cell subset, other

Myeloperoxidase Myeloid

Lysozyme Myeloid, macrophages

CD14 Monocytic cells/macrophages

CD163 Monocytic cells/macrophages

CD33 Myeloid, macrophages, mast cells

Neutrophil elastase Myeloid

CD117 Mast cells, myeloid precursors, other

Tryptase Mast cells

CD34 Progenitor cells, endothelial cells, other

Glycophorin Erythroid

E-cadherin Immature erythroid, other

Factor VIIIRA Megakaryocytes, endothelial cells

CD61 Megakaryocytes

Ki-67/MIB-1 Proliferating cells

P53 Tumor suppressor gene

AE1/AE3 Cytokeratin

Cam 5.2 Cytokeratin

Pankeratin Cytokeratin

S100/S100a Neural, melanoma & other

CD207/Langerin Langerhans cells

EBV-ISH (EBER) Epstein-Barr virus

EBV-LMP Epstein-Barr virus

Parvovirus Parvovirus

CMV Cytomegalovirus

HHV8 Human herpes virus-8

H.Pylori H. Pylori

B. henselae Bartonella henselae

HSV 1/2 Human herpes viruses 1 & 2

Molecular Diagnostic and Cytogenetic Testing

MOLECULAR DIAGNOSTIC TEST ORDERING: MOLECULAR DIAGNOSTICS WEBSITE:

http://path.upmc.edu/divisions/mdx/diagnostics.html

printable requisition form

information on required sample types for each test

frequently asked questions are answered

Request on BM specimens should be given to BM technologists – message can be left on the Audix line (802-3273). On lymph node service, please fax requisition and save with fax “receipt” in notebook in room G323. It is also preferred that you call to inform them a fax is coming. Lymph node assistant or backup should help. The molecular oncology testing schedule (after DNA/RNA preparation) is as follows (updated 1/2012; subject to change per MDX policy) Monday/Thursday: TCR, IgH, JAK2, BCL-2 PCR testing is started and results out the next day Wednesday: Quantitative BCR-ABL and Quantitative PML testing is started and results out Thursday or Friday Wednesday: TCR, IgH, BCL-2 Southern blot testing is started and results out the following Tuesday

Please see below for example of requisition form. Additional Testing Information: Specialty labs will do PCR for B. henselae from frozen specimens or paraffin sections (test is not validated for paraffin sections). Their number is 800-421-7110, Pacific Time, if you have specific questions. The samples should be sent through Molecular Diagnostics, as for TB. Testing for Whipple disease can be arranged through the molecular diagnostics laboratory also.

CYTOGENETICS TEST ORDERING: Please be sure that the pathology requisition is attached to the cytogenetics requisition and that the cytogenetic requisitions have at least the following information:

Name of the patient and numerical identifier Pathologist’s name Clinician’s name (if clear on requisition not necessary to repeat) Reason for sending specimen (“r/o lymphoma” should be fine for all of our specimens unless

you have different or more specific information to provide)

Please see below for example of cytogenetics requisition form as well as testing menu

http://path.upmc.edu/divisions/mdx/diagnostics.html

PITTSBURGH CYTOGENETICS LABORATORY

Oncology Cytogenetic Study Requisition form

PATIENT INFORMATION (Please Print) REFERRING PHYSICIAN (Please Print) Last Name: First: M.I.: Name:

Address: Address:

City, State, Zip: City, State, Zip:

Birthdate: ___________________ Sex: ______ Male ______ Female Social Security #: ___________________

Telephone:

Medical Record #: Account#: Inpatient? _____ Location: _______________ Outpatient? _____

Fax:

Specimen information:

Date/Time of Collection: _______________ Amount Drawn: ________ Additional Report To:

Type of Specimen:

_____ Bone Marrow _____ Peripheral Blood (unstimulated)* _____ Tumor type (location)__________________________ _____ Lymph Node (location)_________________________

* Peripheral blood may be submitted for unstimulated studies only if circulating blast count is above 5%.

Address:

City, State, Zip:

Phone: Fax:

Clinical History/Pertinent Physical Findings (include chemotheraphy and radiation therapy dates/drugs):

____Pre-Bone Marrow Transplant Sex of Donor: ____Male ____ Female ____ Post-Bone Marrow Transplant #days _____

Signature of Requesting Physician (REQUIRED!):

INDICATION FOR STUDY: (MUST BE COMPLETED!) * CIRCLE ALL THAT APPLY *

Anemia Thrombocytopenia Leukocytosis Leukopenia Pancytopenia Lymphoma Other (Specify)

Diagnosis: Tentative Confirmed New Diagnosis? Remission Sample? Relapse Sample?

CML: Chronic Phase Blast Phase ALL: B-ALL T-ALL CLL MM MPD (Specify)

MDS AML Other (Specify)

TEST(S) REQUESTED: (MUST BE COMPLETED!) * CIRCLE ALL THAT APPLY *

Chromosome Analysis (Karyotype) Yes No

Fluorescence in-situ hybridization (FISH) panels requested: * CIRCLE ALL THAT APPLY * MDS Panel MPD Panel AML Panel CLL Panel MM Panel Children’s ALL

Panel B-Cell lymphoma Panel

FLUORESCENCE IN SITU HYBRIDIZATION (FISH)

Monosomy/Trisomy Translocation/fusion Break-apart rearrangement Solid tumors

___5q- ___BCR/ABL t(9;22) ___ALK (2p23) ___MLL (11q23) ___12CEP/12p

___Monosomy 7/ 7q-

___BIRC3/MALT t(11;18)

___AML1 (21q22)

___MYC (8q24)

___1p36/19q

___Trisomy 8

___CBFβ/MYH1 inv(16)

___BCL2 (18q21)

___PAX5 (9p13)

___ALK (2p23)

___Trisomy 9

___ETV6/RUNX1 t(12;21)

___BCL3 (19q13)

___PDGFRB (5q33) ___RARA (17q21)

___CHOP (12q13)

___Trisomy 12

___IGH@/FGFR3 t(4;14)

___BCL6 (3q27))

___TCF3 (19p13) ___TCL1 (14q32)

___ERBB2/CEP17

___13q-

___IGH@/BCL2 t(14;18)

___BCL10 (1p22)

___TCRAD (14q11)

___EWSR1 (22q12)

___20q-

___IGH@/CCND1 t(11;14)

___CCND1 (11q13) ___EVI1 (MECOM) (3q26)

___TCRB (7q34)

___FKHR(FOXO1) (13q14)

___Hyperdiploidy 5, 7, 9

___IGH@/MAF t(14;16) ___FGFR1 (8p12) ___TCRG (7p14) ___MONOSOMY 3

___ATM (11q-)

___IGH@/MALT1 t(14;18) ___IGH (14q32) ___TEL(ETV6) (12p13) ___N-MYC

___CMYB (6q-)

___IGH@/MYC t(8;14) ___IGK (2p11) ___TLX1 (10q24) ___SYT (18q11.2)

___P16(CDKN2A) (9p21)

___PML/RARA t(15;17) ___IGL (22q11) ___TLX3 (5q35) ___TLS(FUS) (16p11.2)

___P53 (del 17p13.1) ___MALT1 (18q21

PITTSBURGH CYTOGENETICS LABORATORY

Oncology Cytogenetic Study Requisition form

___RUNX1T1/RUNX1 t(8;21)

___PAX5 (del 9p13)

___CHIC2/FIP1L1-PDGFRA (4q12)

___XX/XY Others (Specify):_______________________________________________________________________________

Updated: 3/25/13 JH Magee-Womens Hospital of UPMC

300 Halket St., Rm. 1225 Pittsburgh, PA 15213

(412)641-5558 PHONE (412)641-2255 FAX

Cytogenetics Test Menu

CYTOGENETICS Blank Slides Available Order Blanks - See Page One

Break Apart Rearrangement Probes Other

ALK (2p23) RARA (17q21) ASS deletion (9q34) AML1 (21q22) TCRB (7q34) ATM deletion (11q22.3) BCL2 (18q21) TCRG (7p14) CEP X/Y BCL3 (19q13) TCRAD (14q11) D7S486/CEP7 -7/7q31 I (7q) BCL6 (3q27) TCR3 (19p13) (D7S522/CEP7) - 7/7q31 BCL10 (1p22) TCL1(14q32.1) Deletion 13q (13q14) D135319 CBFB (16q22) Deletion 20q (20q12) D205108 CCND1 (11q13) Translocation Probes EGR1 -5/5q- ETV6 (TEL) (12p13) RUNX1T1/RUNX1 (ETO/AML1) t(8;21) AML FIP1L1-CHIC2-PDGFRA(4q12) (CHIC2 deletion) EVI1 (MECOM) (3q26.2) BIRC3-MALT1 (API2-MALT1) t(11;18) CDKN2A (p16) (9p21 deletion) EWSR1 (22q11.2) BCR-ABL t(9;22) CML/ALL/AML TP53 deletion (17p13.1) FGFR1 (8p12) IGH - CCND1 (T11:14) Trisomy 5, 9, 15 IGH (14q32) IGH-BCL2 t(14;18) Trisomy 8 D8Z2 IGK (2p11) CBFB-MYH1 (16p13/16q22) t(16;16). inv(16) Trisomy 12 D1273 IGL (22q11) IGH-FGFR3 t(4;14) MALT1 (18q21) IGH-MAF t(14;16) MLL (11q23) IGH MALT1 t(14;18) MYC (8q24) IGH-MYC t(8;14) MYCN (2P23-24) (for amp) PML-RARA t(15;17) PAX5 (9p13) TEL-AML1 (ETV6/RUNX1) t(12;21) PDGFRB (5q33)

Panels B-Cell Lymphoma - BCL6 (3q27) / MYC (8q24) / IGH (14q32.3) / BCL2 (18q21) CLL - MYB (6q23) / ATM (11q22.3) / trisomy 12 / D13S319 (13q14.3) / IGH (14q32.3) / p53 (17p13.1) Multiple Myeloma MM - D13S319 (13q14.3) / ATM (11q22.3) / p53 (17p13.1) / IGH (14q32.3) / CCND1 (11q13) Childrens' ALL - CEP4/CEP10/CEP17 (trisomies 4, 10, 17) / BCR/ABL [t(9;22)] / MLL (11q23) / TEL-AML1 (ETV6/RUNX1) t((12;21) Childrens' AML - EGR1 (5q31) / monosomy 7 / ETO-AML1 (RUNX1T1/RUNX1) [t(8;21)] / MLL (11q23) / CBFB [inv(16)] MDS/AML - EGR1 (5q31) / D7S486 (7q31)-CEP7 / trisomy 8 / D2OS108 (20q12) AML Panel - EGR1 (5q31) / D7Z1 - D7S486 / RUNX1T1-RUNX1[t(8;21)] / CBFB [inv(16) or t(16;16)] / MLL [t(11;var)] [as needed (i.e. if not seen by classical analysis)]

MPD panel - BCR-ABL1 / CEP8 / CEP9 / D2OS108 (20q12) Myeloid/lymphoid neoplasm with eosinophilia - FIP1L1-CHIC2-PDGFRA (4q12), PDGFRB (5q33), FGFR1 (8p13)

Additional FISH Probes Request (please list) Requested Ordered Blanks Sent Comments

FISH panels for Hematologic Malignancies

CLL Panel

DNA Probe Chromosome Breakpoint 1. D13S319/LAMP2 13q14.3 2. CEP 12 12p11.1-q11.1 3. ATM 11q22.3 4. p53 17p13.1 5. CMYB 6q23 6. IGH 14q32.3*

*If IGH is positive, we may recommend a few translocation probes involving 14q32 a. IGH/BCL2 t(14;18)(q32;q21) b. IGH/CCND1 t(11;14)(q13;q32)

Multiple Myeloma (MM) Panel

DNA Probe Chromosome Breakpoint 1. IGH 14q32.3 2. IGH/CCND1 14q32/11q13 3. TP53/CEP17 17p13.1 4. D13S319/LAMP1 13q14.3 5. D5S23/D5S721,9q34,CEP7 5p15.2, 9q34, 7p11.1-q11.1

(hyperdiploidy)

If IGH is + and IGH/CCND1 is -, then we will do FISH for:

IGH/FGFR3 t(4;14)(p16;q32)

IGH/MAF t(14;16)(q32;q23) If classical chromosome analysis is normal and the above MM FISH panel is negative, then the following FISH will be performed reflexively:

ALL panel

DNA Probe Chromosome Breakpoint 1. BCR/ABL 9q34/22q11.2 2. MLL 11q23 3. ETV6/RUNX1 12p13/21q22

(TEL/AML1) 4. CEP4 4p11-q11 5. CEP10 10p11.1-q11.1 6. CEP17 17p11.1-q11.1

B-Cell Lymphoma Panel

DNA Probe Chromosome Breakpoint 1. BCL6 3q27 2. MYC 8q24 3. IGH 14q32 4. BCL2 18q21

MDS Panel DNA Probe Chromosome Breakpoint

1. EGR1 5q31 2. CEP 7 7p11.1-q11.1 3. D7S486 7q31 4. CEP 8 8p11.1-q11.1 5. D20S108 20q12

MPD Panel

DNA Probe Chromosome Breakpoint 1. BCR/ABL 9q34/22q11.2 2. CEP 8 8p11.1-q11.1 3. CEP 9 9p11-q11 4. D20S108 20q12

AML Panel

DNA Probe Chromosome Breakpoint 1. D7Z1/D7S486 7p11.1-q11.1/7q31 2. EGR1 5q31/5p15.2 3. RUNX1T1/RUNX1 8q22/21q22

(ETO/AML1) 4. CBFB 16q22 [inv(16)] 5. MLL 11q23

MALT Lymphoma Strategy

DNA Probe Chromosome Breakpoint

1. MALT1 18q21*

*If MALT1 is positive, we will recommend a few translocation probes involving 18q21

a. IGH/MALT1 t(14;18)(q32;q21) b. API2/MALT1 t(11;18)(q21;q21)

CML Strategy ES probe

1. BCR/ABL ES t(9;22)(q34;q11.2)* *If the extra signal is not observed using the BCR/ABL ES DNA probe and the cells are positive for the fusion signal in a considerable proportion of cells, perform FISH using the LSI ASS (9q34) DNA probe to detect a deletion of 9q.

*If there is suspicion for the acute phase or blast phase of CML, we may suggest the following FISHes to detect trisomy 8 and/or i(17q) using the following DNA probes:

a. CEP 8 8p11.1-q11.1 b. RARA/CEP17 17q21

CoPath and Dictation Pointers

COPATH Related Instructions for Dictation of Final Reports 1. At time of dictating any report, the patient name, the CoPath pathology report number,

the medical record number should be stated in all instances except the occasional consult in which this information is not available. With the exception of the other cases, the number put in the dictaphone should be the MR number. At the end of the dictation, state that this is the end of the dictation on ____________ (given patient’s name).

2. The trainee dictating at the end of the final diagnosis can state “do not mark this case complete.” In this instance, the transcriptionist will not finalize the case by marking it “complete” during the transcription process. If the report is dictated before noon, within two hours it will be available for correction by the trainee. If it is dictated afternoon, four hours later, the report will be available for corrections. In all instances, reports dictated before the four o’clock cut-off would be transcribed on the same day. The trainee then can go into the report and edit the final diagnosis and microscopic (as well as the gross and clinical history they choose) and when finished they must mark the case as “complete” which will then sent to the physician’s electronic sign-out queue. During this process the trainee is to verify that the final diagnosis matches that written on the hard copy during sign-out. If a report is not ready, contact the secretarial supervisor. The trainee should then give the paperwork including a printed final copy to the staff pathologist.

The trainee should ask the faculty person if the above is what they want. If not, be sure to given the faculty person all paperwork.

3. All “UP” cases (white or yellow sheet consults) must have a billing code dictated. These consult cases have either a white or yellow sheet on the folder containing the consult case. Blue sheet consults (usually performed at request of clinician) do not need a billing code dictated.

4. Cut off times: Cases dictated by 5:00 PM Monday – Friday will be typed that day Cases dictated after 5:00 PM Monday – Friday will be typed by 10:00 AM the

next day Saturday: cases dictated by 12 Noon will be typed that day

BILLING CODES FOR “UP” CASES (“WHITE” OR “YELLOW” SHEET CONSULTS)

BC# Consultation Type

1 Level I Consult (very simple review, no extra stains)

2 Level II Consult (greater than 4 H&E, or up to 3 IHC stains)

3 Level III Consult (4-7 IHC stains)

4 Level IIII Consult (complex with 8-11 IHC stains)

5 Level V Consult (complex with ≥12 IHC stains)

6 Lymph Nodes with Flow Cytometry and No Immunostains

14 No Charge (including VA flows)

15 Stains, only

FLOW/IHC cases -- coded comments for discussion Coded comments to add to end of microscopic description after immunostain table or if there is no immunostain table (because it will be in an addendum) under “Ancillary Studies.” FLOW/IHC1: Medical necessity justification for the immunohistochemical stains that were needed in addition to the flow cytometric immunophenotypic studies for the best diagnosis possible is as follows: The flow cytometric studies did not define the precise nature of all the cellular elements of concern in this specimen. [to be used for example if a cyclin D1 stain with other markers is needed or if flow didn't evaluate a plasma cell or possible RS population] FLOW/IHC2: Medical necessity justification for the immunohistochemical stains that were needed in addition to the flow cytometric immunophenotypic studies for the best diagnosis possible is as follows: The flow cytometric studies are not clearly representative of all the features requiring evaluation in this specimen. [To be used for example if you have lymphoid aggregates in marrow that might not be in the flow suspension, suspension was dilute] Coded comment to add to end of flow report when it will precede the complete report with the above coded comments: FLOW1: Because these flow cytometric studies do not fully clarify the diagnosis in this case, immunohistochemical stains will be performed on this specimen and a final report will follow.

Division of Hematopathology Dictating & Proofing Tissue Reports*

(Suggestions for trainees) Patient history:

Look at prior cases in CoPath worksheet, outside reports, requisitions, MARS (if patient is or has been at UPMC), letter (if consult) for historical information and be sure to include in report since, in part, some or all of this information may be very hard to find at a later date. This is OUR responsibility. For bone marrow cases, the technologists often enter a clinical history, but it is up to us to verify the accuracy and completeness.

Be sure pre-op, post-op diagnoses and procedure have been entered. Diagnosis:

Be sure to use standard format o Tissue type, tissue site, procedure (and if consult, Outside slide number “OSS….,

institution”)- diagnosis using terminology of WHO (if malignant)

NEVER use “consistent with” in a diagnostic line. This is departmental policy.

If more than one specimen on a consult, the different parts should be in chronological order.

Abbreviations should be avoided; if used in a report, the full term should be provided the first time it is used.

Comment:

Be sure that the comment includes the methods used to arrive at the diagnosis. Phenotypic aberrancies that might be useful to follow up on in any subsequent specimens are useful to include here. Ask the attending pathologist if there is any question about what should be included in the comment.

The comment should stress the major diagnosis first and must be consistent with the diagnoses listed above (i.e.: it should not “back-track” on a definitive diagnosis).

The comment does not necessarily have to follow the same order as the specimens listed in the diagnosis (i.e., a definitive diagnosis might be dealt with first).

Be sure at least the comment, if not the diagnosis, clearly indicates any studies still pending at the time of signout. These should not come as a surprise to the physician receiving the report.

Microscopic description

Microscopic descriptions should “conjure up” and clearly convey an image that is consistent with the diagnosis. “Buzz words” can be used to help achieve brevity and, while it is best to avoid using descriptions to make conclusions, there is no need to describe all the features of obviously reactive follicles or T-zone nodules.

Microscopic descriptions in general should start with a statement concerning the tissue type, the low magnification architectural features and then the relevant cytologic features. Special stains should then follow and then the IHC/ISH template (if any such stains have been performed).

IHC tables should follow the part that has been described in multipart specimens – easiest way so it’s clear what they refer to.

Cases with flow cytometric studies and immunostains MUST HAVE a FLOW/IHC1 or 2 comment at the end of this section.

On consult cases with prior flow cytometric studies, the outside flow reports should at least be summarized including a statement as to which laboratory did the studies. Place after (or before) the IHC/ISH results.

On “UP” consult cases, be sure to dictate a billing code at the end. Cases with flow plus just H&E sections get BC6. Our other UP cases with 4-7 special stains will be BC3, more complex cases will be BC4 (8-11 special stains), with the most complex cases with greater than 12 stains getting BC5.

Synoptic reports

A synoptic should be added to all bone marrow and solid tissue reports when a hematopathologic/lymphoid neoplasm is being diagnosed. Currently on the bone marrows, these are being added on first-time diagnoses only, although they do not need to be limited to those cases.

There are currently four (4) synoptics used in Hematopathology. o Bone Marrow/Peripheral Blood Hematopoietic/Lymphoid Disorders Synoptic o Gastrointestinal Lymphoma Resection Synoptic o Hodgkin Lymphoma Biopsy/Staging Synoptic o Non-Hodgkin’s Lymphoma Biopsy/Resection Synoptic

Synoptic reports may be dictated using the templates included this manual. A

hard copy is available in rooms G315 and G323. Alternatively, they can be manually entered in CoPath after case dictation.

Instructions for the use of synoptics are available online. The CoPath user guide is posted on the CoPathPlus website http://copath.upmc.com under the link for CoPathPlus Training Resources. The Synoptic Data Entry and Reporting Chapter is Chapter 24.

Proofreading

Proofread reports carefully and MAKE SURE that what is written not only is what was intended at sign out but that it makes sense. If proofing prior to giving to a faculty member and something doesn’t make sense, at least communicate that to them.

Be sure to proof numbers that have been included (including in the flow reports)

Be sure that immunostain designations are what you intended (i.e., sometimes CD45RO/UCHL1 gets entered instead of CD45/LCA).

Be sure singular/plural forms of words are correct, reports say “and” where you meant “and” and not “in”, “intra-“and “inter-“are used appropriately.

Be sure the templated tables don’t have capital letters in the middle of a sentence.

Unless directed otherwise, give the faculty member a printed out final version of your final report – not something with handwriting or a draft.

Be sure to make an arrangement with the faculty member to see what changes were made in what you considered to be a final report.

[Revised 10/2013]

http://copath.upmc.com/

Wording for Provisional Reports on Lymph Node Biopsies

Provisional reports may be when there is a delay in issuing a complete final report. These are now a type of “special procedure”. These are to be used only on rare occasions.

When dictating the case, the transcriptionist must be instructed to type a provisional report.

Be sure the comment includes the following: This represents a provisional report. It will be replaced by a final diagnostic report once…

Hematopathology Case Worksheet in CoPath 1. Log into CoPath. 2. From the top menu bar, choose FILE. 3. Choose BROWSE ITEMS. 4. Look in the Browse Items menu list. Scroll down until you get to HEME WORKSHEET. 5. Click and drag to your menu on the left so that this report will be available to you the next

time you log in. 6. Double click on HEME WORKSHEET. The report will take 1 minute to load. 7. Type the specimen number in the box under "Select a Specimen." 8. Click on ADD. 9. Run the report by clicking on OK. 10. Click on PRINT.

Resident/fellows can now review and print out the results of the special procedures that have been signed out by following the directions given below. The print out will also include the original diagnosis.

Special Procedure Review by Resident/Fellow in CoPath

1. Log into CoPath. 2. From the top menu bar, choose FILE. 3. Choose BROWSE ITEMS. 4. Look in the Browse Items menu list. Scroll down until you get to PROCEDURE REVIEW BY

RESIDENT/FELLOW. 5. Click and drag to your menu on the left so that this report will be available to you the next

time you log in. 6. Double click on PROCEDURE BY RESIDENT/FELLOW. 7. Choose the data field criteria desired to run the report:

Typically for the data field:

Choose the time range or date for Sign Out Date.

For Specimen Class choose ALL VALUES

For Procedure choose ALL VALUES

For Person, click in the circle next to Individual Items, highlight the name of the resident/fellow, then click on ADD. (You can add multiple names.)

8. Run the report by clicking OK. 9. The next time you log in to CoPath, you can just choose the PROCEDURE BY RESIDENT/FELLOW report from your menu on the left and eliminate steps 2 to 5 above.

SYNOPTICS

Bone Marrow/Peripheral Blood Hematopoietic/Lymphoid Disorders Synopti

Specimen #:

Patient:

Part:

Initials/Date:

6.5

This is a worksheet. It is NOT the final diagnosis.

- - - - - - - - - - - - - - - - MACROSCOPIC - - - - - - - - - - - - - -

SPECIMEN TYPE/PROCEDURE**

(check all that apply)

A1 Aspirate

A2 Biopsy

A3 Particle Preparation

A4 Blood film

A5 Cell block (Clot section)

A6 Touch imprint

A7 Not specified

BIOPSY/ASPIRATE SITE**

B1 Not applicable

B2 Right posterior iliac crest

B3 Left posterior iliac crest

B4 Other (specify):

B5 Not specified

ADEQUACY OF SPECIMEN**

C1 Satisfactory

C2 Limited

C3 Unsatisfactory

C4 See report

- - - - - - - - - - - - - - - - MICROSCOPIC - - - - - - - - - - - - - - -

W HO CLASSIFICATION** (check all that apply)

Note: This is NOT the final diagnosis. Use final diagno

/comment for therapeutic decisions.

Myeloproliferative Neoplasms

D1 Chronic myelogenous leukemia, BCR-ABL+

D2 Chronic myelogenous leukemia, accelerated phase

D3 Chronic myelogenous leukemia, myeloid blast crisis

D4 Chronic myelogenous leukemia, lymphoid blast crisis

D5 Chronic myelogenous leukemia, blast crisis, NOS

D6 Chronic neutrophilic leukemia

D7 Chronic eosinophilic leukemia, NOS

Mastocytosis

D8 Cutaneous mastocytosis

D9 Systemic mastocytosis

D10 Systemic mastocytosis with associated clonal,

hematologic non-mast-cell lineage disease

D11 Aggressive systemic mastocytosis

D12 Mast cell leukemia

D13 Mast cell sarcoma

D14 Extracutaneous mastocytoma

---W HO Classifications Continued on Next Page----


Specimen #:

Patient:

Part:

Initials/Date:

6.5


W HO CLASSIFICATION (check all that apply) CONT'

D15 Polycythemia vera

D16 Primary myelofibrosis

D17 Essential thrombocythemia

D18 Myeloproliferative neoplasm, unclassifiable

D19 Possible myeloproliferative neoplasm, see report

D20 Favor myeloproliferative neoplasm but must rule out

other possibilities, see report

Myeloid and Lymphoid Neoplasms with Eosinophilia and

Abnormalities of PDGFRA, PDGFRB OR FGFR1

D21 Myeloid and lymphoid neoplasms with PDGFRA

rearrangement

D22 Myeloid neoplasms with PDGFRB rearrangement

D23 Myeloid and lymphoid neoplasms with FGFR1

rearrangement

Myelodysplastic/ Myeloproliferative Neoplasms

E1 Chronic myelomonocytic leukemia

E2 Atypical chronic myeloid leukemia, BCR-ABL-

E3 Juvenile myelomonocytic leukemia

E4 Myelodysplastic/myeloproliferative neoplasm,

unclassifiable

E5 Refractory anemia with ring sideroblasts associated

with marked thrombocytosis

Myelodysplastic Syndromes

F1 Refractory anemia

F2 Refractory neutropenia

F3 Refractory thrombocytopenia

F4 Refractory anemia with ringed sideroblasts

F5 Refractory cytopenia with multilineage dysplasia

F6 Refractory cytopenia with multilineage dysplasia and

ringed sideroblasts

Refractory anemia with excess blasts (RAEB)

F7 RAEB-1

F8 RAEB-2

F9 Myelodysplastic syndrome, unclassifiable

F10 Myelodysplastic syndrome associated with isolated

del(5q)

F11 Childhood myelodysplastic syndrome

F12 Refractory cytopenia of childhood

F13 Possible myelodysplastic syndrome, see report

F14 Favor myelodysplastic syndrome but must rule out

other possibilities, see report

F15 Myelodysplastic syndrome, classification pends

cytogenetics



Specimen #:

Patient:

Part:

Initials/Date:

6.5



Acute Myeloid Leukemias (AML)

G1 Acute myeloid leukemia, not otherwise classified

Acute myeloid leukemia with recurrent genetic

abnormalities

G2 AML witH t(8;21)(q22;q22); RUNX1-RUNX1T1

G3 AML with inv(16)(p13.1q22) or t(16;16)(p13.1;q22);

CBFB-MYH11

G4 Acute promyelocytic leukemia with t(15;17)(q22;q12);

PML-RARA

G5 AML with t(9;11)(p22;q23); MLLT3-MLL

G6 AML with t(6:9)(p23;q34); DEK-NUP214

G7 AML with inv(3)(q21q26.2) or t(3;3)(q21;q26.2);

RPN1-EVI1

G8 AML (megakaryoblastic) with t(1:22)(p13;q13);

RBM15-MKL1

G9 AML with mutated NPM1

G10 AML with mutated CEBPA

Acute myeloid leukemia with myelodysplasia-related

changes

G11 AML with myelodysplasia - Following a

myelodysplastic syndrome or myelodysplastic

syndrome/myeloproliferative disorder

G12 AML with myelodysplasia - Without antecedent

myelodysplastic syndrome

G13 AML with myelodysplasia - With unknown prior

history

Therapy-related myeloid neoplasms

G14 Therapy-related myeloid neoplasms c/w AML

G15 Therapy-related myeloid neoplasms c/w MDS

G16 Therapy-related myeloid neoplasms c/w MDS/MPN

G17 Therapy-related myeloid neoplasm, NOS

Acute myeloid leukemia not otherwise categorized

G18 AML with minimal differentiation

G19 AML without maturation

G20 AML with maturation

G21 Acute myelomonocytic leukemia

G22 Acute monoblastic and monocytic leukemia

G23 Acute erythroid leukemia

G24 Acute megakaryoblastic leukemia

G25 Acute basophilic leukemia

G26 Acute panmyelosis with myelofibrosis

G27 Acute myeloid leukemia, final classification pends

cytogenetic studies

G28 Myeloid sarcoma



Specimen #:

Patient:

Part:

Initials/Date:

6.5



Myeloid proliferations related to Down syndrome

G29 Transient abnormal myelopoiesis

G30 Myeloid leukemia associated with Down syndrome

G31 Blastic plasmacytoid dendritic cell neoplasm

Acute leukemias of ambiguous lineage

G32 Undifferentiated acute leukemia

G33 Mixed phenotype acute leukemia with

t(9;22)(q34;q11.2); BCR-ABL1

G34 Mixed phenotype acute leukemia with t(v;11q23);

MLL rearranged

G35 Mixed phenotype acute leukemia, B/myeloid, NOS

G36 Mixed phenotype acute leukemia, T/myeloid, NOS

G37 Natural killer (NK) cell lymphoblastic

leukemia/lymphoma

Mixed phenotype acute leukemia, NOS

G38 Bilineal acute leukemia

G39 Biphenotypic acute leukemia

G40 Acute leukemia, uncertain lineage

Precursor lymphoid neoplasms

B lymphoblastic leukemia/lymphoma

H1 B lymphoblastic leukemia/lymphoma, NOS

H2 B lymphoblastic leukemia/lymphoma with recurrent

genetic abnormalities

H3 B lymphoblastic leukemia/lymphoma with

t(9;22)(q34;q11.2); BCR-ABL1

H4 B lymphoblastic leukemia/lymphoma with t(v;11q23);

MLL rearranged


t(12;21)(p13;q22) TEL-AML 1 (ETV6-RUNX1)

H6 B lymphoblastic leukemia/lymphoblastic lymphoma

with hyperdiploidy

H7 B lymphoblastic leukemia/lymphoma with hypodiploidy

(hypodiploid ALL)


t(5;14)(q31;q32) IL 3-IGH


t(1;19)(q23;p13.3); E2A-PBX1 (TCF3-PBX1)

H10 B lymphoblastic leukemia/lymphoma, final

classification pends cytogenetic studies

H11 T lymphoblastic leukemia/lymphoma


J1 B-cell lymphoid neoplasm, not further classified

J2 Small B-cell lymphoid neoplasm, not further classified

J3 Chronic lymphocytic leukemia/small lymphocytic

lymphoma



Specimen #:

Patient:

Part:

Initials/Date:

6.5



J4 B-cell prolymphocytic leukemia

J5 Waldenstrom macroglogulinemia

Heavy chain diseases

J6 Alpha heavy chain disease

J7 Gamma heavy chain disease

J8 Mu heavy chain disease

J9 Splenic marginal zone lymphoma

J10 Hairy cell leukemia

J11 Splenic B-cell lymphoma/leukemia, unclassifiable

J12 Splenic diffuse red pulp small B-cell lymphoma

J13 Hairy cell leukemia-Variant

J14 Lymphoplasmacytic lymphoma

J15 Plasma cell myeloma

J16 Monoclonal gammopathy of undetermined significance

(MGUS)

J17 Solitary plasmacytoma of bone

J18 Extraosseus plasmacytoma

J19 Plasma cell neoplasm, not further categorized

J20 Primary amyloidosis

J21 Extranodal marginal zone lymphoma of

mucosa-associated lymphoid tissue (MALT-lymphoma)

J22 Nodal marginal zone lymphoma

J23 Pediatric nodal marginal zone lymphoma

Follicular lymphoma

J24 Follicular lymphoma, Grade not defined

J25 Follicular lymphoma - Grade 1-2

J26 Follicular lymphoma - Grade 3

J27 Follicular lymphoma - Grade 3A

J28 Follicular lymphoma - Grade 3B

J29 Pediatric follicular lymphoma

J30 Mantle cell lymphoma

J31 Diffuse large B-cell lymphoma (DLBCL), NOS

J32 T-cell/histiocyte rich large B-cell lymphoma

J33 Primary DLBCL of the CNS

J34 Primary Cutaneous DLBCL, leg type

J35 EBV positive DLBCL of the elderly

J36 DLBCL associated with chronic inflammation

J37 Lymphomatoid granulomatosis

J38 Primary mediastinal (thymic) large B-cell lymphoma

J39 Intravascular large B-cell lymphoma

J40 ALK positive large B-cell lymphoma

J41 Plasmablastic lymphoma

J42 Large B-cell lymphoma arising in HHV8-associated

multicentric Castleman disease

J43 Primary effusion lymphoma

J44 Burkitt lymphoma



Specimen #:

Patient:

Part:

Initials/Date:

6.5



J45 B-cell lymphoma, unclassifiable, with features

intermediate between diffuse large B-cell lymphoma


J46 B-cell lymphoma, unclassifiable, with features



Mature T-Cell and NK-Cell Neoplasms

K1 T-cell prolymphocytic leukemia

K2 T-cell large granular lymphocytic leukemia

K3 Chronic lymphoproliferative disorder of NK-cells

K4 Aggressive NK-cell leukemia

K5 Systemic EBV positive T-cell lymphoproliferative

disease of childhood

K6 Hydroa vacciniforme-like lymphoma

K7 Adult T-cell leukemia/lymphoma

K8 Extranodal NK/T-cell lymphoma, nasal-type

K9 Enteropathy associated T-cell lymphoma

K10 Hepatosplenic T-cell lymphoma

K11 Subcutaneous panniculitis-like T-cell lymphoma

K12 Mycosis fungoides

K13 Sézary syndrome

K14 Primary cutaneous CD30 positive T-cell

lymphoproliferative disorders

K15 Primary cutaneous anaplastic large cell lymphoma

K16 Lymphomatoid papulosis

K17 Primary Cutaneous gamma-delta T-cell lymphoma

K18 Primary cutaneous CD8 positive aggressive

epidermotropic cytotoxic T-cell lymphoma

K19 Primary cutaneous CD4 positive small/medium T-cell

lymphoma

K20 Peripheral T-cell lymphoma, NOS

K21 Angioimmunoblastic T-cell lymphoma

K22 Anaplastic large cell lymphoma, ALK positive

K23 Anaplastic large cell lymphoma, ALK negative

Hodgkin Lymphoma

L1 Nodular lymphocyte predominant Hodgkin lymphoma


L2 Nodular sclerosis classical Hodgkin lymphoma

L3 Lymphocyte-rich classical Hodgkin lymphoma

L4 Mixed cellularity classical Hodgkin lymphoma

L5 Lymphocyte-depleted classical Hodgkin lymphoma

L6 Classical Hodgkin lymphoma, not further categorized

L7 Hodgkin vs non-Hodgkin lymphoma

Histiocytic & Dendritic-Cell Neoplasms

M1 Histiocytic sarcoma

M2 Langerhans cell histiocytosis

M3 Langerhans cell sarcoma



Specimen #:

Patient:

Part:

Initials/Date:

6.5



M4 Interdigitating dendritic cell sarcoma

M5 Follicular dendritic cell sarcoma

M6 Fibroblastic reticular cell tumor

M7 Indeterminate dendritic cell tumor

M8 Disseminated juvenile xanthogranuloma

M9 Dendritic cell sarcoma, not otherwise specified

Other

N1 Malignant neoplasm, type cannot be determined

Post-transplant lymphoproliferative disorders

P1 Plasmacytic hyperplasia

P2 Infectious mononucleosis-like PTLD

P3 Polymorphic PTLD

P4 Monomorphic PTLD (specify type):

P5 Classical Hodgkin-lymphoma type PTLD

ANCILLARY STUDIES**

Flow Cytometry-Phenotyping**

Q1 Flow cytometry immunophenotype performed, see

separate report

Q2 Flow cytometry immunophenotype pending, report to

follow

Q3 Flow cytometry immunophenotype not performed

Immunohistochemistry/In Situ Hybridization**

R1 Immunohistochemistry/ in situ hybridization performed,

see microscopic description

R2 Immunohistochemistry/ in situ hybridization pending,

see addendum

R3 Immunohistochemistry/ in situ hybridization not

performed

Classical Cytogenetic Studies**

S1 Classical cytogenetic studies performed, see separate

report

S2 Classical cytogenetic studies pending, report to follow

S3 Classical cytogenetic studies not performed

Cytogenetic FISH Studies**

T1 Cytogenetic FISH studies performed, see separate

report

T2 Cytogenetic FISH studies pending, report to follow

T3 Cytogenetic FISH studies not performed

Genotypic (Molecular) Studies**

U1 Genotypic (Molecular) studies performed, see separate

report

U2 Genotypic (Molecular) studies pending, report to follow

U3 Genotypic (Molecular) studies not performed

U4 DNA stored,Genotypic (Molecular) studies not

performed

U5 RNA stored,Genotypic (Molecular) studies not

performed


Specimen #:

Patient:

Part:

Initials/Date:

6.5


Cytochemical Stains**

V1 Cytochemical stains performed, see microscopic

description

V2 Cytochemical stains pending, see addendum

V3 Cytochemical stains not performed

ADDITIONAL PATHOLOGIC FINDINGS

Y1 Specify:

EXTENT OF BONE MARROW /PERIPHERAL BLOO

INVOLVEMENT

W1 Acute leukemia/MDS (bone marrow) - % blasts W2

Acute leukemia/MDS (peripheral blood) - % blasts W3

Malignant lymphoma - approximately % of area

involved

Multiple myeloma

W4 Plasma cells <10%

W5 Plasma cells 10%-30%

W6 Plasma cells >30%

OVERALL MARROW CELLULARITY**

X1 <10% X2

10-20%

X3 21-40%

X4 41-60%

X5 61-80%

X6 81-100%

X7 Variable, see report

X8 Not applicable

Comment:

Non-Hodgkins Lymphoma Biopsy/Resection Synoptic Template

Specimen #:

Patient:

Part:

Initials/Date:

6.2


- - - - - - - - - - - - - - - - MACROSCOPIC - - - - - - - - - - - - - -

SPECIMEN TYPE**

A1 Lymphadenectomy (specify sites):

A2 Other (specify):

A3 Not specified

A4 Splenectomy

A5 Other extranodal (specify):

PROCEDURE (select all that apply)**

B1 Fine needle aspiration

B2 Needle core biopsy

B3 Biopsy, other

B4 Resection

B5 Other (specify):

B6 Unknown

TUMOR SITE (check all that apply)**

C1 Lymph node(s), site unknown

C2 Lymph node(s) - Specify site(s),

C3 Other tissue(s) - Specify site(s):

C4 Not specified

C5 Only one site biopsied, see above

- - - - - - - - - - - - - - - - MICROSCOPIC - - - - - - - - - - - - - - -

HISTOLOGIC TYPE (W HO CLASSIFICATION)**



D1 Histologic type cannot be assessed

D2 Non-Hodgkin lymphoma vs Hodgkin lymphoma

B-cell Lymphoma

D3 B-cell lymphoma, subtype cannot be determined

D4 B-cell lymphoma with high grade features

D5 B-lymphoblastic leukemia/lymphoma, NOS

D6 B lymphoblastic leukemia/lymphoma with recurrent

genetic abnormalities

D7 B lymphoblastic leukemia/lymphoma with

t(9:22)(q34;q11.2); BCR-ABL1

D8 B lymphoblastic leukemia/lymphoma with t(v;11q23);

MLL rearranged


t(12;21)(p13;q22) TEL-AML 1 (ETV6-RUNX1)

D10 B lymphoblastic leukemia/lymphoma with hyperdiploidy

D11 B lymphoblastic leukemia/lymphoma with hypodiploidy

(hypodiploid ALL)


t(5;14)(q31;q32) IL 3-IGH

---Histologic Types Continued on Next Page----


Specimen #:

Patient:

Part:

Initials/Date:

6.2


HISTOLOGIC TYPE (W HO CLASSIFICATION)** (co


t(1;19)(q23;p13.3); E2A-PBX1

D14 Chronic lymphocytic leukemia/small lymphocytic

lymphoma

D15 B-cell prolymphocytic leukemia

D16 Splenic marginal zone lymphoma

D17 Hairy cell leukemia

D18 Splenic B-cell lymphoma/leukemia, unclassifiable

D19 Splenic diffuse red pulp small B-cell lymphoma

D20 Hairy cell leukemia-variant

D21 Lymphoplasmacytic lymphoma

D22 Waldenstrom macroglobulinemia

D23 Heavy chain disease

D24 Alpha heavy chain disease

D25 Gamma heavy chain disease

D26 Mu heavy chain disease

D27 Plasma cell myeloma

D28 Solitary plasmacytoma of bone

D29 Extraosseous plasmacytoma

D30 Extranodal marginal zone lymphoma of

mucosa-associated lymphoid tissue (MALT lymphoma)


mucosa-associated lymphoid tissue (MALT lymphoma)

with plasmacytic differentiation


mucosa-associated lymphoid tissue (MALT lymphoma),

pediatric

D33 Nodal marginal zone lymphoma

D34 Nodal marginal zone lymphoma with plasmacytic

differentiation

D35 Nodal marginal zone lymphoma, pediatric

D36 Marginal zone lymphoma, not further specified

D37 Marginal zone lymphoma with plasmacytic

differentiation, not further specified

Follicular Lymphoma

Grade

D38 Follicular lymphoma, grade 1-2

D39 Follicular lymphoma, grade 3A

D40 Follicular lymphoma, grade 3B

Growth Pattern

D41 Follicular lymphoma, growth pattern - follicular

D42 Follicular lymphoma, growth pattern - follicular &

diffuse

D43 Follicular lymphoma, growth pattern - minimally

follicular

D44 Follicular lymphoma, growth pattern not specified

D45 Follicular lymphoma, not further specified



Specimen #:

Patient:

Part:

Initials/Date:

6.2



D46 Primary cutaneous follicle center lymphoma

D47 Primary cutaneous follicle center lymphoma vs

follicular lymphoma

D48 Primary cutaneous follicle center lymphoma vs diffuse

large B-cell lymphoma

D49 Primary cutaneous diffuse large B-cell lymphoma, leg

type vs diffuse large B-cell lymphoma, not further

specified

D50 Follicular lymphoma, diffuse follicle center subtype,

grade 1-2

D51 Mantle cell lymphoma

D52 Diffuse large B-cell lymphoma (DLBCL), NOS, germinal

center phenotype

D53 Diffuse large B-cell lymphoma (DLBCL), NOS,

non-germinal center phenotype

D54 Diffuse large B-cell lymphoma (DLBCL), NOS, not

further specified

D55 T-cell/histiocyte rich large B-cell lymphoma

D56 Primary DLBCL of the CNS

D57 Primary Cutaneous DLBCL, leg type

D58 EBV positive DLBCL of the elderly

D59 DLBCL associated with chronic inflammation

D60 Lymphomatoid granulomatosis

D61 Primary mediastinal (thymic) large B-cell lymphoma

D62 Intravascular large B-cell lymphoma

D63 ALK positive large B-cell lymphoma

D64 Plasmablastic lymphoma

D65 Large B-cell lymphoma arising in HHV8-associated

multicentric Castleman disease

D66 Primary effusion lymphoma

D67 Burkitt lymphoma

D68 B-cell lymphoma, unclassifiable, with features



D69 B-cell lymphoma, unclassifiable, with features



D70 B-cell Lymphoma - Other (specify):

T-cell Lymphoma

D71 T-cell lymphoma, subtype cannot be determined

D72 T-lymphoblastic leukemia/lymphoma

D73 T-cell prolymphocytic leukemia

D74 T-cell large granular lymphocytic leukemia

D75 Chronic LPD of NK-cells

D76 Aggressive NK-cell leukemia

D77 Systemic EBV positive T-cell lymphoproliferative

disease of childhood

D78 Hydroa vacciniforme-like lymphoma

D79 Adult T-cell leukemia/lymphoma



Specimen #:

Patient:

Part:

Initials/Date:

6.2



D80 Extranodal NK/T-cell lymphoma, nasal type

D81 Enteropathy-associated T-cell lymphoma

D82 Hepatosplenic T-cell lymphoma

D83 Subcutaneous panniculitis-like T-cell lymphoma

D84 Mycosis fungoides

D85 Sézary syndrome

D86 Primary cutaneous anaplastic large cell lymphoma

D87 Lymphomatoid papulosis

D88 CD30 positive lymphoproliferative disease, NOS

D89 Primary cutaneous gamma-delta T-cell lymphoma

D90 Primary cutaneous CD8-positive aggressive

epidermotropic cytotoxic T-cell lymphoma

D91 Primary cutaneous CD4-positive small/medium T-cell

lymphoma

D92 Peripheral T-cell lymphoma, NOS

D93 Angioimmunoblastic T-cell lymphoma

D94 Anaplastic large cell lymphoma, ALK positive

D95 Anaplastic large cell lymphoma, ALK negative (provisional)

D96 T-cell Lymphoma - Other (specify):

Other

D97 Blastic plasmacytoid dendritic cell neoplasm

D98 Other (specify):

ANCILLARY STUDIES**

Flow Cytometry-Phenotyping**

E1 Flow cytometry immunophenotype performed, see

separate report

E2 Flow cytometry immunophenotype pending, report to

follow

E3 Flow cytometry immunophenotype not performed


F1 Immunohistochemistry/ in situ hybridization performed,


F2 Immunohistochemistry/ in situ hybridization pending,

see addendum

F3 Immunohistochemistry/ in situ hybridization not

performed


G1 Classical cytogenetic studies performed, see separate

report

G2 Classical cytogenetic studies pending, report to follow

G3 Classical cytogenetic studies not performed

---ANCILLARY STUDIES Continued on Next Page----


Specimen #:

Patient:

Part:

Initials/Date:

6.2


ANCILLARY STUDIES** (cont'd)


H1 Cytogenetic FISH studies performed, see separate

report

H2 Cytogenetic FISH studies pending, report to follow

H3 Cytogenetic FISH studies not performed


J1 Genotypic (Molecular) studies performed, see separate

report

J2 Genotypic (Molecular) studies pending, report to follow

J3 Genotypic (Molecular) studies not performed

J4 DNA stored, Genotypic (Molecular) studies not

performed


K1 Specify:

L5 Involvement of multiple lymph node regions on both

sides of diaphragm

L6 Specify sites:

L7 Splenic involvement

L8 Liver involvement

L9 Bone marrow involvement

L10 Other organ involvement

L11 Specify:

L12 Not specified

CLINICAL PROGNOSTIC FACTORS AND INDICES

(Select all that apply)

M1 International Prognostic Index (IPI) (specify):

M2 Follicular Lymphoma International Prognostic Index

(FLIPI) (specify):

M3 B symptoms present

M4 Other (specify):

EXTENT OF PATHOLOGICALLY EXAMINED TUMO


L1 Involvement of a single lymph node region

L2 Specify site:

L3 Involvement of multiple lymph node regions on same

side of diaphragm

L4 Specify sites:

Comment:

Hodgkin Lymphoma Biopsy/Staging Synoptic Template

Specimen #:

Patient:

Part:

Initials/Date:

- - - - - - - - - - - - - - MACROSCOPIC - - - - - - - - - - - - - - -

SPECIMEN TYPE**

A1 Lymphadenectomy (specify sites):

A2 Staging laparotomy

A3 Extranodal (specify):

A4 Other (specify):

A5 Not specified

PROCEDURE**

B1 Fine needle aspiration

B2 Needle core biopsy

B3 Biopsy, other

B4 Resection

B5 Other (specify):

B6 Unknown

TUMOR SITE (check all that apply)**

C1 Lymph node(s), site not specified

C2 Lymph node(s) - specify sites(s):

TUMOR SIZE (largest single mass) - Resections Only

D1 Greatest dimensions: cm.

D2 Additional dimensions: cm.

D3 Specify site:

D4 Cannot be determined (see Comment)

- - - - - - - - - - - - - - MICROSCOPIC - - - - - - - - - - - - - - - -

HISTOLOGIC SUBTYPE**



E1 Nodular lymphocyte predominant Hodgkin lymphoma

(NLPHL)

E2 Nodular sclerosis classical Hodgkin lymphoma (NSHL)

E3 Mixed cellularity classical Hodgkin lymphoma (MCHL)

E4 Lymphocyte-rich classical Hodgkin lymphoma (LRCHL)

E5 Lymphocyte-depleted classical Hodgkin lymphoma (LDHL)

E6 Classical Hodgkin lymphoma, further subtype cannot be

determined

E7 Hodgkin lymphoma, subtype cannot be determined

E8 Other (specify):

C3 Other tissue(s) or organ(s) - specify

site(s):

C4 Not specified

C5 Only one site biopsied, see above

HISTOLOGIC GRADE (NSHL only) - OPTIONAL

F1 Not applicable

F2 Grade I

F3 Grade ll

F4 Grade uncertain


Specimen #:

Patient:

Part:

Initials/Date:

EXTENT OF PATHOLOGICALLY EXAMINED TUMO


G1 Involvement of a single lymph node region.

Specify site:

G2 Involvement of multiple lymph node regions on the

same side of the diaphragm.

Specify sites:

G3 Involvement of multiple lymph node regions on both

sides of the diaphragm.

Specify sites:

G4 Splenic involvement

G5 Liver involvement

G6 Bone marrow involvement

G7 Other organ involvement

G8 Specify:

G9 Not specified

ANCILLARY STUDIES**

Flow Cytometry - Phenotyping**

H1 Flow cytometry immunophenotype performed, see

separate report

H2 Flow cytometry immunophenotype pending, report to

follow

H3 Flow cytometry immunophenotype not performed


J1 Immunohistochemistry/ in situ hybridization performed,


J2 Immunohistochemistry/ in situ hybridization pending,

see addendum

J3 Immunohistochemistry/ in situ hybridization not

performed


K1 Classical cytogenetic studies performed, see separate

report

K2 Classical cytogenetic studies pending, report to follow

K3 Classical cytogenetic studies not performed


L1 Cytogenetic FISH studies performed, see separate

report

L2 Cytogenetic FISH studies pending, report to follow

L3 Cytogenetic FISH studies not performed


M1 Genotypic (Molecular) studies performed, see separate

report

M2 Genotypic (Molecular) studiending, report to follow

M3 Genotypic (Molecular) studies not performed

M4 DNA stored,Genotypic (Molecular) studies not performed


Specimen #:

Patient:

Part:

Initials/Date:


(check all that apply) N1 Progressive transformation of germinal centers (PTGC)

N2 Castleman disease

N3 Other (specify): ________________________________

CLINICAL PROGNOSTIC FACTORS AND INDICES P1 International Prognostic Score (IPS) (specify):

P2 B symptoms present

P3 Other (specify): ____________

Comment:

Web-Based Resources

WEBSITE EDUCATIONAL RESOURCES & CALL SCHEDULES

Division of Hematopathology Intranet website (Hematopathology schedules/paging and general information) 1. http://path.upmc.edu/divisions/hematopath.html UPMC Pathology Residents Server (includes on call schedule for AP and CP) 1. https://pathologyresidents.shp.upmc.com/SitePages/Home.aspx Hematological Malignancies Program

1. http://www.upmccancercenter.com/portal_hema/overview.cfm For general pathology (Hematopathology, Dermatopathology and others) 1. http://www-medlib.med.utah.edu/WebPath/webpath.html 2. http://dermatlas.med.jhmi.edu/derm (Users can search by categories, diagnoses, or body site) 3. www.uscap.org (numerous teaching resources) 4. http://www.pathologyoutlines.com HEMATOPATHOLOGY Atlas 1. http://www.ashimagebank.org/ 2. http://www.bloodmed.com/home/

Virtual Slide Set

1. https://epssecure.upmc.com/hematopathology/index.cfm (or link via residents web page http://pathologyresidents.shp.upmc.com/SitePages/Home.aspx -- the link to Hematopathology virtual slide set is on the right hand side (direct link to virtual slide set Division of Hematopathology UPMC Presbyterian)

2. http://cclcm.ccf.org/vm/VM_cases/lymphoid_main.htm (Virtual Hematopathology slides (and other fixed images) from Cleveland Clinic) 3. www.uscap.org (Virtual Slide Box at USCAP) General

1. http://www.sh-eahp.org/ 2. http://medmark.org/hem/ 3. http://www.cancer.gov/ (treatment of leukemias/lymphoma) Case Studies 1. http://path.upmc.edu/cases.html 2. http://teachingcases.hematology.org/ USCAP Hematopathology Evening Session Cases

1. http://www.uscap.org/ Societies 1. http://www.hematology.org/ 2. http://www.aspho.org/ 3. http://www.blacksci.co.uk/uk/society/bsh/default.htm 4. http://www.leukemia.org/

http://path.upmc.edu/divisions/hematopath.html

http://www.upmccancercenter.com/portal_hema/overview.cfm

http://dermatlas.med.jhmi.edu/derm

http://www.uscap.org/

http://www.pathologyoutlines.com/

http://www.ashimagebank.org/

http://www.bloodmed.com/home/

https://epssecure.upmc.com/hematopathology/index.cfm

http://pathologyresidents.shp.upmc.com/SitePages/Home.aspx

http://cclcm.ccf.org/vm/VM_cases/lymphoid_main.htm


http://www.sh-eahp.org/

http://medmark.org/hem/

http://www.cancer.gov/

http://path.upmc.edu/cases.html

http://teachingcases.hematology.org/


http://www.hematology.org/

http://www.aspho.org/

http://www.blacksci.co.uk/uk/society/bsh/default.htm

http://www.leukemia.org/

Educational Site

1. http://www.cyto.purdue.edu/index.htm

2. http://flowcyt.cyto.purdue.edu/flowcyt/educate/pptslide.htm

3. http://enjoypath.com/

Cases and Tests 1. http://www.madsci.org/~lynn/VH/APIII/CPflow.html Societies

1. http://www.cytometry.org/

2. http://www.isac-net.org/ Books

1. http://www.cyto.purdue.edu/cdroms/cyto2/14/pucl/flowcyt/refclin.htm CYTOGENETICS 1. http://www.pathology.washington.edu/galleries/Cytogallery/main.php

Flow Cytometry 1. http://www.bloodjournal.org/content/bloodjournal/111/8/3941.full.pdf

NOTE: IF THERE ARE ANY SITES YOU FEEL SHOULD BE ADDED TO THIS LIST OR DEFUNCT SITES, PLEASE LET DR. SWERDLOW OR DR. GIBSON KNOW

Online Conference Access for Pathology Faculty and Residents Visit Department of Pathology Conference Access for Pathology Faculty and Residents http:/pathologyconference.upmc.edu Weekly Conference includes:

Anatomic Pathology Grand Rounds conference Departmental Seminar (Archived)

These LIVE and archived conferences are only accessible through the UPMC network.

Note: Additional non-web based resources are in UPMC-Presbyterian G304, G315 and G323.

http://www.cyto.purdue.edu/index.htm

http://flowcyt.cyto.purdue.edu/flowcyt/educate/pptslide.htm#http://flowcyt.cyto.purdue.edu/flowcyt/educate/pptslide.htm

http://enjoypath.com/

http://www.madsci.org/~lynn/VH/APIII/CPflow.html

http://www.cytometry.org/

http://www.isac-net.org/

http://www.cyto.purdue.edu/cdroms/cyto2/14/pucl/flowcyt/refclin.htm

http://www.pathology.washington.edu/galleries/Cytogallery

http://www.bloodjournal.org/content/bloodjournal/111/8/3941.full.pdf

http://teleconference.upmc.edu/index.html

Documents

DIVISION OF HEMATOPATHOLOGY - UPMC - Department of Pathology