HISTOPATHOLOGY UNIT

Head of Unit Dr. Nik hasimah Nik Yahya Phone +603 2615 5555 extension 5595/5619 Email nikhasimah@gmail.com

1. INTRODUCTION

Histopathology Unit is divided into 3 subsections:

i. Routine laboratory

ii. Specialised laboratory (Special stain, immunohistochemistry and molecular histopathology laboratory)

iii. Neuromuscular laboratory

2. WHERE TO FIND US

Routine Histopathology and Specialised Laboratories are located within the main laboratory complex of Pathology Department. The Neuromuscular and Molecular Laboratory is situated in Institute of Neurology at Level 1. Diagnostic consultation with histopathologists is at Pusat Diagnostic Anatomik Patologi (PDAP), which is situated at Dermatology Institute next to Dermatology Auditorium.

3. TO CONTACT US:

1. Head of Unit and Consultant Pathologist (Dr. Nik Hasimah Nik Yahya) : 5619

2. Histopathology office : 5595

3. Report enquiry : 5603

4. Pathologist : 5619, 5707, 5704

5. Microscopy Room (Medical Officer and Scientific Officer) : 6851

6. Routine, Special Stain and Molecular Histopathology Laboratory : 5605

7. Neuropathology Laboratory : 6651

8. Senior Medical Lab Technologist : 6572

4. SERVICES PROVIDED

1. General histopathological examination of tissue (routine HPE)

2. Frozen section

3. Histochemistry (Special Stain) – refer to Appendix 1 for list of special stain

4. Immunohistochemistry (IHC) – refer to Appendix 2 for list of antibodies for IHC.

5. Immunofluorescent microscopy (IMF) – refer to Appendix 3 for list of antibodies for IMF.

6. Enzyme histochemistry – refer to Appendix 4 for list of enzymes for enzyme histochemistry.

7. Clinical autopsy

8. Molecular histopathology (Her-2 In-situ hybridization) for breast cancer

5. SUBSPECIALTY SERVICE

1. Paediatric pathology

2. Neuropathology

3. Renal pathology

4. Neuromuscular pathology

5. Urological pathology

6. Gynecological pathology

7. Bone and soft tissue pathology

8. Dermatopathology List of Consultant Pathologists with subspecialties and their contact details can be found in Appendix 5.

6. OUT-OF-HOURS SERVICE

A histopathologist is rostered for 24 hours call to cater for frozen section and clinical autopsy services as well as surgical pathology consultation. He / she can be contacted through the hospital operator.

7. HOW TO MAKE A REQUEST FOR ROUTINE HISTOPATHOLOGY

EXAMINATION OR OTHER HISTOPATHOLOGY SERVICE. 7.1 General (routine) histopathology.

Use PER-PAT 301 carbonized request form filled in with relevant clinical information for all histopathological examination requests. If the report is needed urgently, please mark the request form URGENT clearly at the top right hand corner.

Histopathology Laboratory requires a set of request form (3 carbonized copies) for each request. A request with multiple specimens only requires one set (3 carbonized copies) of request form.

7.2 Frozen section.

All requests for frozen section examination must be preceded by appointment and discussion with the Surgical Pathologist on-call at least 1 day before the operation. This is followed by filling up of the request form for the frozen section and submitting it to the Histopathology Laboratory for notification.

Request form for frozen section (HKL/JP/HI/AK-05-02) is available at the Histopathology Office. (Appendix 6 - A).

Please inform the laboratory at extension 5605 or Medical Officer/Pathologist at ext. 6851 if the frozen section examination is cancelled.

All cases scheduled for frozen section examination are best placed first in the operating list. So it can be done during normal working hours.

7.3 Clinical autopsy

Clinical autopsy or postmortem examination is conducted to ascertain the cause of death in non-medicolegal cases. This service is only provided for patients who died in Kuala Lumpur Hospital.

The following procedure should be followed:

1. The requesting doctor shall first obtain written consent from the next of kin. Use Borang Keizinan Bedah Siasat Mayat Klinikal (Autopsi Klinikal HKL/JP/HI-BP-02). This consent form is available at the mortuary counter of Forensic Department, Kuala Lumpur Hospital.

2. In cases where the next of kin is not available, the Hospital Director and one medical specialist will have to give their consent.

3. In case of a foreigner where the next of kin is not available, consent from their respective embassy officials is required.

4. The clinician who requests for post-mortem shall communicate directly with the Histopathology Medical Officer or Pathologist on call.

5. Postmortem examination is usually performed during office hour but requests can be made after office hour if necessary.

6. During office hour, the Medical Officer/ Pathologist on call for clinical postmortem can be contacted at extension 6851 or 5603.

7. After office hour, the Histopathology Medical Officer and Pathologist on call can be contacted through telephone. Duty roster of Histopathology Medical Officer /Pathologist on call and their contact numbers are available at the mortuary counter of Forensic Department (ext. 6695) and hospital operator.

8. A clinical summary together with the case notes and consent form shall be sent to the Medical Officer or Pathologist on duty.

9. The requesting specialist from the clinical department is required to be present during the autopsy.

7.4 Specialised histopathology services / Referrals

Histopathology Unit provides specialized histopathology services in areas as listed above. Referrals or cases for expert or second opinion are welcome.

i. For consultation :

The client (pathologist or clinician) can communicate directly with the Pathologist specialized in the respective field.

ii. Referral for expert or second opinion :

For HKL patients that need expert or second opinion, the requesting doctor (clinician) is required to fill up the request form as routine cases and submit it to Histopathology Laboratory together with the specimen (paraffin embedded tissue, stained and/or unstained slides). Paraffin embedded tissue is preferred if the cases need further ancillary studies or staining.

For outside cases, the material together with referral letter should be sent to

Histopathology Laboratory. The request should be directed or addressed to

the specific Pathologist depending on the specialty. The fax number where

the report needs to be sent to should be provided by the requesting doctor.

The general referral cases or cases other than the above listed subspecialties

will be reported by the pathologist on call on that particular day.

If the case has been reported elsewhere, a copy of the report should be

provided.

8. SPECIMEN COLLECTION AND CONTAINERS

All specimens for routine histological examination are to be fixed in 10% neutral buffered formalin (NBF) in a suitable clean leak-proof container. The containers should have wide opening and if possible with screw cap to prevent leakage. The volume of formalin used must be at least 10 times the volume of specimen to be fixed. Do not put large specimen in small containers as this would prevent proper fixation of the tissue and also distort the specimen. All specimen containers should have the same identification details as that written on the request forms. Multiple small specimens such as gastrointestinal biopsies should ideally be mounted on a piece of filter paper and immediately put in formalin. Specimens from different anatomical sites should be sent in separate containers, properly labelled and must be clearly itemized in the request form. For cases that require confirmation of the adequacy of surgical excision, the margins of the specimen must be marked or tagged accordingly by sutures or by diagrammatic representation of the excised specimen. Specimen for frozen sections should be sent in a clean container without fixative. Specimen for enzyme histochemistry (acetyl cholinesterase) studies is to be sent fresh immediately without fixative in closed containers and moistened with normal saline to prevent drying. 8.1 Muscle biopsy

All requests for muscle biopsy must have prior arrangement with the pathologist concerned or Medical Lab Technologist (MLT) at extension 5605 at least one day before the procedure. (Usually the biceps or quadriceps muscle would suffice in most cases)

Important information to be included in the request form are :

Creatine kinase level

LDH

Contact no. of treating clinician relevant hospital fax number

Familt history of similar problems. For open biopsy:

Remove at least one good cylinder of muscle measuring 1.0x0.5x0.5 cm, the smaller diameter being the cross-section of the muscle.

For optimal processing muscle specimen must be wrapped with aluminium foil and sent fresh in an air tight, dry and clean container.

The specimen should be transported in a container containing ice or gel ice. (Never use dry ice).

Do not tie the muscle to stretch it and do not put tissue on gauze.

The laboratory will accept fresh muscle biopsy specimen up to 4 hours upon removal but please remember that optimal result requires the specimen to be as fresh as possible.

8.2 Renal biopsy

Prior arrangement with the Pathologist concerned is preferred for very urgent requests. Two specimens are recommended for each case for proper histopathological evaluation, i.e formalin fixed tissue for ordinary light microscopy examination and fresh tissue for immunofluorescent staining. Renal biopsy tissue for immunofluorescence:

Take at least 3 mm core of fresh tissue.

The specimen should be sent fresh in a clean air tight container.

o If the specimen cannot reach the laboratory immediately, the fresh tissue should be put in phosphate buffer, properly packed and transported in ice or gel ice.

Do not put fresh tissue specimen on gauze.

9. DESPATCH AND TRANSPORTATION OF HISTOPATHOLOGY SPECIMEN

Specimens for routine histopathological examination should be sent directly to Histopathology Laboratory (not at the common specimen reception counter). Fresh tissue specimen for frozen section, immunofluorescent staining and enzyme histochemistry should be sent immediately to Histopathology Laboratory. Fresh tissue should be properly packed and transported in ice or dry ice if the specimen cannot reach the laboratory immediately (especially specimen from other hospitals). For frozen section, the specimen should be sent immediately upon removal to Histophatology laboratory by a doctor who will wait for the report. Muscle biopsy specimen should be sent to Histopathology Laboratory (Pintu 6).

10. HISTOPATHOLOGY REPORTS

Reports of biopsies for histopathological examination which are labelled ‘urgent’ will be available within 1 week after receipt of the specimens by the laboratory (unless the case needs further staining, second opinion etc). NOTE: Please leave the requesting doctor’s name and contact number on the request form for early flagging of results. Results of frozen section will be immediately communicated to the surgeon via telephone or the doctor who brought the specimen to the laboratory. 10.1 Report enquiry

Report enquiries can be made via extension 5603. Accession number of the specimen (HPE number) can be obtained using Labviewer in the respective ward or clinic. The accession number is the last five digits of the request code which starts with 33XXXXX. Please identify your request according to specimen sent to the laboratory.

The requesting doctors are welcome to discuss the cases directly with the reporting Pathologist or Medical Officer concerned at extension 6851.

10.2 Collection of report

All histopathology reports shall be collected by respective clinics / wards / department from histopathology office.

Request for a second copy shall be made in writing or using form PERMOHONAN MENDAPATKAN SALINAN LAPORAN HPE UNIT HISTOPATOLOGI (HKL/JP/HI-BP-04) (Appendix 6 - B)

11. AFTER OFFICE HOURS SPECIMEN

All specimens for routine histological examination taken after office hours should be fixed in the usual manner (in formalin) in the respective OT or ward and keep at room temperature. The specimen should then be despatched to the Histopathology Laboratory during operating working hours and Saturday from 900 am to 1200 noon.

12. INTERDEPARTMENTAL CLINICOPATHOLOGY CONFERENCE

Histopathology Unit conducts clinicopathology conference (CPC) with the major clinical departments in Kuala Lumpur Hospital on a monthly basis. The schedule for the whole year is issued before every new year begins. The clinical department concerned is required to submit the list of patients to be discussed to the Histopathology Office at least one week before the schedule date.

Enquiries about clinicopathology conference should be communicated directly to the Medical Officer in charge or Pathologist concerned at extension 6851 or 5603.

13. TAKING OUT PARFFIN BLOCKS/SLIDES FROM HISTOPATHOLOGY UNIT.

Patients’ paraffin blocks and slides are archived in Histopathology Unit. For certain valid reasons the unit allows the clinician to take diagnostic material (paraffin block / slide) from the Unit. The following procedures must be followed.

i. The request to borrow the diagnostic material must be made by a specialist.

ii. The requesting specialist needs to fill up a form PERMOHONAN PEMINJAMAN / PENGAMBILAN BAHAN DIAGNOSTIK UNIT HISTOPATOLOGI (HKL/JP/HI-BP-01) (Appendix 6 - C) which is available at Histopathology office.

iii. The completely filled form should be submitted to Histopathology Office and the material can be taken within 3 working days upon submitting the form to the office.

iv. The paraffin block and stained slides must be returned to Histopathology Office within 1 month.

14. TAKING OUT TISSUE FROM HISTOPATHOLOGY UNIT.

All specimens (tissue) sent to and officially received by Histopathology Laboratory will be kept in the unit up for 3 months after the official report is released. The Histopathology Unit allows the patient to take their tissue, organ or limb back upon request. Please follow this procedure.

i. The patient or next kin must make a formal request by filling up a form PERMOHONAN PENGAMBILAN SPECIMEN / TISU UNIT HISTOPATOLOGI (HKL/JP/HI-BP-02) (Appendix 6 - D).

ii. This form is available in Histopathology Office.

iii. The completed form should be submitted to Histopathology Office.

iv. The tissue is released only after the specimen has been reported by the Pathologist.

15. REQUEST TO OBTAIN MICROSCOPIC IMAGE FROM HISTOPATHOLOGY UNIT.

Microscopic images are not archived as routine but images can be provided upon request. A request shall be made or endorsed by specialist.

i. For presentation :

The requesting doctor should communicate directly with the Pathologist concerned.

A request shall be made by filling up a form i.e PERMOHONAN MENDAPATKAN GAMBAR HISTOPATOLOGI (HKL/JP/HI-BP-03) (Appendix 6 - E). Which is available at the Histopathology Office. The completed form should be submitted to the Histopathology Office.

ii. For publication :

The requesting doctor shall communicate directly with the Pathologist concerned followed by filling up the request form.

The abstract of the publication should be provided and the Pathologist concerned who reported the case should be included as co-author.

The microscopic histopathology images will be available within 2 weeks upon submission of the

form. Only soft copy of the images is provided and the requester should provide a CD before

collecting the images from the unit.

16. RESEARCH

The histopathology unit welcome research projects or studies to be done in collaboration with our unit.

All collaborative studies or research projects must have approval from the Head of Pathology Department.

A copy of research proposal must be provided.

One pathologist from the unit shall be appointed as collaborator or co-researcher.

The researcher will be assisted by the appointed Pathologist to retrieve the materials required if the research project requires archival material from this unit.

All archival slides can be borrowed for review in the unit only.

If paraffin blocks are required for further testing, sections should be done at the allocated station in this laboratory.

No archival material should be taken out from Histopathology Unit.

Appendix 1

LIST OF ANTIBODIES FOR HISTOCHEMICAL STAIN 1. Alcian Blue

2. Congo Red

3. Cresyl Fast Violet

4. Fouchet (Bile)

5. Giemsa

6. Gomori Trichrome

7. Gram

8. Grocott-Gomori Methena Silver (GMS)

9. Leder Giemsa

10. Luxol Fast Blue

11. Masson Fontana

12. Masson Tichrome

13. Martius Scarlet Blue

14. Melanin Bleach

15. Mucicarmine

16. Oil Red O (Fat)

17. Orcein

18. PAAG

19. Periodic acid Schiff (PAS)

20. PAS / Alcian Blue

21. PAS + D

22. PAS + D/ Alcian Blue

23. Perl Prussian Stain

24. PTAH

25. Reticulin (Gordon/Sweet)

26. Rubeanic acid

27. Schmorl's reaction

28. Toluidine blue

29. Van Gieson

30. Von Kossa

31. Verhoeff Elastic Van Gieson (EVG)

32. Wade Fite

33. Warthin Starry

34. Ziehl-Neelson

Appendix 2

LIST OF ANTIBODIES FOR IMMUNOHISTOCHEMICAL STAIN 1. ALK protein

2. AMACR

3. Amyloid A

4. Alfa-feto protein A

5. Alfa-1 anti trypsin

6. ACTH (AdenocorticontrophinHormon)

7. B-CATENIN

8. BCL 2

9. BCL 6

10. BSEP

11. CA 125

12. CD 1 - ALPHA

13. CD 2 (T-Cell)

14. CD 3(T cell)

15. CD 4

16. CD 5(T cell)

17. CD 7

18. CD 8

19. CD 10

20. CD 15(Hodgkin's)

21. CD 20(B cell)

22. CD 21

23. CD 23

24. CD 30(Ki-1) Antigen

25. CD 31(Endothelial cell)

26. CD 34

27. CD 43 (Hematologi)

28. CD 56 (NKT-cell)

29. CD 61 (Hematologi)

30. CD 68(Macrophage)

31. CD 79 Alpha(B cell)

32. CD99 (Mic2 Gens)

33. CD 117

34. CD 138 (Hematologi)

35. CD 163

36. CD235a - Glycophorin A (Hematologi)

37. CDK4

38. CDX2

39. Calcitonin

40. Caldesmon 41. Calretinin

42. CEA(Carcino Embryonic Antigen)

43. Chromogranin

44. CK 5/6

45. CK 7

46. CK 19

47. CK 20

48. CK AE1/AE3

49. CK MNF 116

50. CMV (Cytomegalovirus)

51. C4d

52. C1q

53. C3

54. Cyclin D1

55. D2 40

56. Desmin

57. DOG 1

58. E-Cadherin

59. EBV(Epstein Barr Virus)

60. EMA (Epithelial Membrane Antigen)

61. ER(Estrogen receptor)

62. ERG

63. Epithelial antigen

64. F8 (Factor V111 R Ag)

65. Fli-1

66. FSH(Follicle Stimulating Hormone)

67. GFAP(Glial fibrillary acidic protein)

68. GH(Growth Hormone)

69. GLUT 1

70. H-Caldesmon

71. HER-2

72. Hepatocyte Antigen

73. HHV8

74. HMW CK

75. HbSAg (Hep. B Surface Antigen)

76. HL ADR

77. HPL

78. HCG(H. Chorionic Gonadotropin)

79. HPV (Human papilloma virus)

80. HMB45

81. HSV

82. IDH 1

83. Inhibin

84. IgA

85. IgG

86. IgM

87. KI 67

88. Kappa

89. Lambda

90. LCA(Leuco. Com. Antigen)

91. LH(Luteinizing Hormone) 92. Lysozyme

93. Mammaglobin

94. MDR3

95. Melan A

96. MUM 1

97. MPO (Hematologi)

98. Myogenin

99. Myoglobin

100. MYO D1

101. MUC-2

102. MUC-4

103. Napsin A

104. NEU-N

105. NSE(Neurone Specific Enolase)

106. NB84

107. NF (Neurofilament)

108. PSA (Prostate Specific Antigen)

109. P16

110. P40

111. P53

112. P57

113. P63

114. PAX 5

115. PLAP

116. PR (Progesteron Receptor)

117. Prolactin

118. PAX 8

119 RCC

120. SAT B2

121. SMA

122. SNF5 (INI-1)

123. SOX 10

124. STAT 6

125. SV40

126. Synaptophysin

127. S100

128. Tdt

129. TFE3

130. TLE 1

131. TSH

132. TTF1

133. Thyroglobulin

134. Toxoplasma gondii

135. Vimentin

136. Wilm's tumour 1

Appendix 3

LIST OF ANTIBODIES FOR IMMUNOFLUORESCENT STAIN

1. IgG

2. IgA

3. IgM

4. C3

5. C1q

6. Fibrinogen

Appendix 4

LIST FOR ENZYMES FOR ENZYME HISTOCHEMICAL STAIN

A/ RECTAL BIOPSY FOR HIRCHSPRUNG’S DISEASE Acetylcholinesterase B/ MUSCLE BIOPSY FOR NEUROMUSCULAR DISORDER 1. Acid phosphatase

2. Alkaline phosphatase

3. AT Pase (pH 4.3 TO 10.9)

4. Cytochrome Oxidase

5. Cytochrome Oxidase /Succinate dehydrogenase 6. NADH-TR 7. Succinate dehydrogenase

APPENDIX 5

CONSULTANT HISTOPATHOLOGISTS, SUBSPECIALTIES AND CONTACT DETAILS

Pathologist Name Field Of Subspecialty Email Address Tel Ext. No.

Dr. Arni Talib Head Of Department

Paediatric Pathology arni.talib@yahoo.com.my 5594/5619

Dr. Nik Hasimah Nik Yahya Head Of Unit

Renal Pathology nikhasimah@gmail.com 5619

Datin Dr. Fauziah Kassim Neuropathology drfauziahk@gmail.com 5623

Dr. Suryati Mohd Yusoff Neuromuscular Pathology drsuryati88@gmail.com 5707

Dr. Zanariah Alias General Histopathology & Cytology

zanzainal@yahoo.com 5707

Dr. Razmin Ghazali Gynaecological Pathology razmin1967@gmail.com 5243

Dr. Noraini Mohd. Dusa Bone And Soft Tissue Pathology

noraini.mdusa@gmail.com 5704

Dr. Rosna Yunus Urological Pathology yrosna@yahoo.com.my 5704

Dr. Hemlata Kumari Gnanasegaram

Transplant Renal Pathology hm.kumari12@gmail.com 5244

Dr. Zuliatul Faizah Baharom Training in Dermatopathology zuliatulfaizah@gmail.com 5243

Dr. Subasri Armon General Histopathology & Cytology

sarmon2003@gmail.com 5244

Note: Please be informed that all Histopathologists now have moved to PUSAT

DIAGNOSTIC PATOLOGI ANATOMIK which is situated at level 1, Institute of

Dermatology Block next to Dermatology Auditorium.

APPENDIX 6 - A

BORANG PERMINTAAN FROZEN SECTION

APPENDIX 6 - B

PERMOHONAN MENDAPATKAN SALINAN LAPORAN HPE UNIT

HISTOPATOLOGI

APPENDIX 6 - C

PERMOHONAN PEMINJAMAN / PENGAMBILAN BAHAN DIAGNOSTIK

UNIT HISTOPATOLOGI

APPENDIX 6 – D (1)

PERMOHONAN PENGAMBILAN SPECIMEN / TISU UNIT

HISTOPATOLOGI

APPENDIX 6 – D (2)

PERMOHONAN PENGAMBILAN SPECIMEN / TISU UNIT

HISTOPATOLOGI

APPENDIX 6 – E

PERMOHONAN MENDAPATKAN GAMBAR HISTOPATOLOGI