Histology comes of age

Automating the lab
Bert Dotson, manager of the surgical pathology lab at Duke University Medical Center in Durham, NC, says many traditionally manual procedures have finally been automated. But he notes, “In histology, we are just barely touching the surface of automation.” High on the list of those procedures that are now being automated is staining. “Two pieces that were not included — pre-staining and post-staining — now are being incorporated into automated systems,” he says.

Kerry Crabb, president of the National Society for Histotechnology (NSH) in Columbia, MD, agrees, adding, “Much of the routine H&E (hematoxylin and eosin) staining is automated now.”

Tracey Lenek, acting manager of Calgary Laboratory Services in Alberta, Canada, is hoping to automate fully all staining procedures being done in this commercial pathology lab which operates under the umbrella of Alberta Health Services. But she notes, “It is still cheaper to stain manually. It is three to four times more expensive per slide to automate.”

Michelle Lamphere, lead histotechnologist at Children’s Medical Center in Dallas, TX, applauds the timesaving benefits of automated staining. “You just stick your slide on and walk away,” she says. While some automatic stainers now include all stages of the process in one unit, Lamphere uses an adapter which moves slides from an automatic stainer to automatic cover slipper.

Aside from staining, tissue processing also is being automated, making it easier and faster to embed and section tissue samples, says Calgary’s Lenek.
Essentially, the “second set of eyes” is supposed to come from
experts in the field …. But “If two people need to review the
results, you have doubled the workload.”

While it would normally take 10 to 12 hours to process tissue from a small biopsy, the same procedure can now be done in one to two hours by using a rapid tissue processor. And this is especially important when a STAT diagnosis is needed, she says.

Another area that has largely gone unautomated until recently is workflow tracking, says Duke’s Dotson. But now, by using bar codes and RFID systems, all primary specimen containers and tissue cassettes can be tracked from the time a specimen enters the lab, right up to the time the sample is disposed of, he says. Children’s Lamphere says this kind of minute-to-minute tracking also provides a detailed record of who embedded a specimen, when it was sectioned and when it was stained. Plus, she says that by having a bar code on the slide, “Pathologists can scan the bar code and get information on the patient.”

Research and development
Among the newest automated tissue processors are those that incorporate microwave heating, says NSH’s Crabb. “This decreases the number of reagents needed and shortens the processing time.” Although it was introduced in 1985, microwave processing has been slow to catch on, even though studies have shown it to be more effective than conventional methods.

One such study, led by Pritam Panja at the Meenakshi Ammal Dental College in Chennai, India, compared microwave processing to routine and rapid manual methods. Results obtained from the microwave method showed less tissue shrinkage; high-quality staining; and a much shorter processing time. In addition, it eliminated the use of noxious chemicals like xylene and formalin.

Research into other aspects of histological procedures and on new pieces of equipment is ongoing. For example, Yukako Yagi, assistant professor of pathology at Harvard Medical School in Boston, has been studying and developing newer automated systems, including an automated tissue-sectioning system; automated high-volume, ultra-speed slide digitization; a network and data-management system for the automated histology lab; and an RFID-based asset identification and integration system. Yagi also is working to improve image quality by developing 3D whole slide imaging, multispectral imaging applications, and even digital stains.

Various vendors also are offering new systems including an applied imaging platform for both brightfield and fluorescent applications for use when quantifying biomarkers in tissue sections and microarrays, multiple IHC stains, and highly sensitive mass-spectrometry imaging systems.

Facing challenges
Even as new technologies make labs more efficient, lab managers and techs are facing their share of challenges. For Zu-Hua Gao, MD, division head of anatomical pathology at Calgary Laboratory Services, it is new policies that present some of the most difficult challenges. As an example, he cited the efforts being made to reduce interpretation errors by requiring a second review. “This is becoming a major trend in North America,” he says.

Essentially, the “second set of eyes” is supposed to come from experts in the field. But Gao wonders who would be considered an expert and how that “expert” designation would be determined. Plus, he says, “If two people need to review the results, you have doubled the workload.”

Another of Gao’s concerns is Canada’s Critical Value Communication policy. “If there is a critical diagnosis or a change in a diagnosis, you must inform the clinician immediately.”

There also is a Standard Synoptic Reporting policy that Gao says requires all properties of a cancer, including such attributes as tumor size, grade, and margins, to be reported directly to the patient’s physician. Luckily, templates have already been designed specifically for this report. “We have built in all these templates into our LIS,” Gao says.

While new policies such as these pose an administrative headache, the shortage of qualified techs can have a major long-term impact. “Staffing levels are a huge issue,” says Calgary’s Lenek. “There are not that many techs with anatomical-pathology experience.” Raising even more concern is the fact that the median age of histotechnologists is 49. In five to 10 years, if new techs are not found to replace those who are retiring, the shortage could reach a critical level, she says.

Children’s Lamphere says TV shows like “CSI” have helped in recruiting new techs. But she adds, “People soon find out it is not that glamorous.”

Funding also has become a challenge, Lamphere says. At a time when most labs have to pare their spending, some of the newer technologies that come loaded with “bells and whistles” and a big price tag she simply adds to her wish list.

Richard R. Rogoski is a freelance journalist based in Durham, NC. Contact him at [email protected].

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