Quality Assurance

2008 Laboratory Investigation  
Adequate molecular risk stratification is crucial for modern management of chronic lymphocytic leukemia (CLL) patients. Expression of zeta associated protein -70 (ZAP-70) has been proposed as a surrogate marker for the immunoglobulin variable region (VH) mutation status, and is associated with poor prognosis in CLL. Although recent studies have shown that presence of high-risk cytogenetic/ molecular factors (del11q, del17p, V3-21 usage) can result in discordance between ZAP-70 expression and VH
more » ... mutation status, a direct comparison of ZAP-70 expression as measured by multiparametric flow cytometry, with low to intermediate cytogenetic risk factors (del13q and trisomy 12), has not been characterized. Understanding this relationship has practical significance since the VH mutation status can not be evaluated as a routine clinical test. Design: Data was retrospectively collected from 81 CLL patients who had both ZAP-70 and cytogenetic studies performed between 01/2005 and 09/2007. Patients with the following characteristics were excluded: presence of high risk cytogenetics as mentioned above; lack of either trisomy 12 or del 13q; simultaneous expression of trisomy 12 and del 13q; plus more than 2 concurrent cytogenetic abnormalities. The remaining patients (n = 38) were then separated into two groups, based on the presence of either trisomy 12 or del13q, identified by FISH. The average percent of ZAP-70 expression by multiparametric flow cytometry was compared using the student T test. Molecular genetic studies for the VH mutation status were not performed in this study. Results: There was a statistically significant lower level of ZAP-70 expression in the del13q group (mean ZAP 70 % expression=9.16%) when compared with the trisomy 12 group (mean ZAP 70% expression=19.90%) (p=0.005). Conclusions: We observed a statistically significant decrease of ZAP-70 expression in CLL patients with del13q when compared to those with trisomy 12. This finding is of practical value in molecular risk stratification and management of CLL patients, where routine measurement of VH mutation status is not possible. In addition, the finding provides insights in establishing practical quality control standards for measurement of ZAP-70 by flow cytometric immunophenotyping. Background: Immunohistochemical stains are used for localisation of proteins in cells and tissues. Negative immunohistochemical controls are routinely used to test for the specificity of the staining, but there is no generally accepted protocol for the use of negative controls. Design: We sought to perform a preliminary assessment of the utility of negative control done by omission of the primary antibody through the use of a tissue microarray consisting of 0.6 mm cores of normal tissue from 18 cases. These included 69 different normal tissues. Unstained tissue microarray slides were stained in four different laboratories, using three different automated immunostainers, and different commercial detection kits, including both avidin-biotin and polymer-based detection systems. Results: We found that all slides showed no staining except for endogenous cytoplasmic or extracelluar pigments (lipofuscin, melanin, or hemosiderin) detected in cardiomyocytes, macrophages, substantia nigra cells, hepatocytes, seminal vesicle cells and skin. Weak diffuse staining of cells from the anterior pituitary gland was also detected in the slide of one of the laboratories. Conclusions: Negative controls done with omission of the primary antibody showed no precipitation of chromogenic substrate in the normal tissues, with the exception of very faint staining of the anterior pituitary in a slide from one of four laboratories participating in this study. These results are preliminary but, if validated, suggest that some or all negative controls could be eliminated from routine use. Process Improvement of Surgical Pathology Turnaround Time: A Departmental Effort at a Regional Veterans Affairs Medical Center S Askari, DR Sorenson, SL Ewing, R Skeate. VAMC, Minneapolis; U of Minnesota, Minneapolis. Background: Surgical Pathology (SP) turnaround time (TAT) is a visible parameter of a pathology service and Veterans Affairs Medical Centers across the nation are striving for improvement. Design: In early '06, we benchmarked our SP TAT data against Carey Award winning laboratories that reported an average (ave) TAT of <2 days. Process improvement measures were taken and impact evaluated by retrospective review of QA data. Dictation templates were created for microscopic exam -a result of several staff meetings and input from all pathologists. Secretarial work flow changes were made to enhance timely transcription. Availability of templates enabled more pathologists to self-transcribe, thereby decreasing secretarial workload. Measures were taken to improve staffing. Templates provided new staff members a jumpstart with daily sign-outs. All SP cases accessioned between 7/04 and 8/07 were included. TAT QA data from 1/06-8/07 was compared with data from 7/04-12/05. TAT variability over a quarter was compared between '05 and '07 using ave daily TAT. Audit data of randomly selected oncologic SP reports for data elements from CAP Cancer Protocols was reviewed for '06. Results: Ave TAT of <2 days with a <2-day (d) TAT in >80% cases was achieved within 6 months. Ave TAT between 7/04 and 12/05 was 3 d (R=2.5-3.7); it declined to 2 d (R=1.5-2.8) in '06 and to 1.8 d (R=1.6-2.0) in '07. Comparative 2 nd quarter daily ave TAT showed decreased variability in '07 (ave=1.8 d/case; SD=0.3, R=1.2-2.5; N=3,017) when compared with that of '05 (ave=3.5 d/case; SD=0.7, R=2-5; N=2,820). Audit of 58 randomly selected cases from '06 demonstrated 100% compliance with CAP Cancer Protocols. Conclusions: Departmental effort with multifaceted approach helped reduce TAT by almost half, approaching numbers better than the gold standard set by previous Carey Award winners. Process Improvement in the Histology Laboratory Using a Collaborative Problem Resolution Tool AE Bennett, L McDonald, DE Priganc, G GOSS, JL Hunt. Cleveland Clinic, Cleveland, OH; Orion Advisory, Charlotte, NC. Background: The histology laboratory has little opportunity for automation and is largely run through manual processes. Process improvement, therefore, relies on team investment in changes and dedicated follow through. Tools exist in the business community for directed process improvement and these can be used in the histology laboratory. In our laboratory, the time delay in obtaining recut hematoxylin and eosin (H&E) stains and in obtaining special stains significantly delayed case signout. We used a performance improvement tool called FasTrac™ (Orion Advisory, Inc, Charlotte, NC) to address this gap. Design: The FasTrac™ methodology is a six step collaborative problem solving tool that capitalizes on a cross-functional team. FasTrac™ begins by clearly defining a quantifiable problem and ends with implementation of solutions. During the process, the team members identify the root causes of the problem, implement corresponding solutions, and the result is expected to be closing the performance gap. The entire process takes place in a 12-week time period. Success is judged by improvement in the metric -turnaround time of recut and special stains, in our case. Results: Analysis of average turnaround time from ordering of recut H&E to slide delivery was 24 hours and the average for special stains was 27 hours. Through the collaborative process, solutions were suggested and implemented, including obtaining running logs of orders, distributing recut blocks across all members of the lab, and more frequent batching of special stains. After the 12 week FasTrac™, the recut H&E turnaround time was 4 hours and the special stain turnaround time was 6 hours, on average. The turnaround times have met target for the past 9 months. Conclusions: Gaps in laboratory performance in the laboratories can be addressed using simple, but highly effective collaborative process improvement tools. We demonstrate the use of the FasTrac™ process to close the specific gap of a delay in recut and special stain turnaround times. We were able to significantly reduce both turnaround times and improve overall case sign-out turnaround time. The tool also improved morale in the laboratory by engaging the front-line employees in the process. 1616 Utility of Molecular Fixative UMFIX in Preservation of Morphology and Nucleic Acid Integrity in Paraffin Embedded Surgical Specimens M Cankovic, J Beher, R Robinette, L Whiteley, RJ Zarbo. Henry Ford Hospital, Detroit, MI. Background: Gene and protein expression profiling are used to understand disease process and to identify new prognostic and therapeutic markers. Formalin-fixed paraffin embedded (FFPE) specimens represent the most abundant archival source. Tissues fixed in 10% neutral buffered formalin (NBF) retain good morphologic and protein preservation, but the quality of nucleic acids (DNA and RNA) is compromised. We
doi:10.1038/sj.labinvest.3700743 fatcat:pvegl5cifnaqnji62snilgnizi