Scottish Association of Histotechnology 28th Scientific Meeting Report

The Scottish Association of Histotechnology is pursuing similar initiatives to the AMLS Cellular Pathology Advisory Body such as biobanking and molecular strategies and it was beneficial to see how our Scottish colleagues have approached these new developments.

The meeting was opened by Jane Hair, Deputy Director, Bio-repository, Greater Glasgow & Clyde (GGC) NHS. ‘Gifting Tissue for Research: an NHS Organisational Challenge’ described the modern tissue bank in place at GGC, the necessary legal and ethical framework created for biobanking and policy and procedures in use at GGC to facilitate access to patient tissue. Gifting of surplus surgical tissue is a vital research resource. The tissue bank at GGC is a stand alone non-project specific bank. It contains a range of sample types including snap frozen and formalin fixed tissue and also stores related clinical information. New legislation introduced in the UK; The Human Tissue Act (2004) aimed to restore public confidence in the scientific community who use human tissue for research. It promoted the enormous benefits of human tissue research while introducing better measures protecting the rights of society and individuals. This law gave specific guidelines on consent; when it was required and not required. The Human Tissue (Scotland) Act (2006) was consistent with legislation in UK and Wales and based on ‘authorisation’ instead of ‘consent’. Standards for Tissue Banks were created following this legislation based on ethical principles. There must be Accountability; transparency in policy & systems. Human samples treated as gifts rather than commodities, Traceability: donor to research end user and Accessibility; there must be a fair access policy for researchers. The National Research Ethics Service was formed and created the Research Ethics Committee (REC). This committee performs ethical review of research projects and approves the use of bio-banked tissue for specific research projects without requiring consent or authorisation from individual patients. It is important to note that the patient has already consented or authorised to surplus tissue being used for ‘general’ research. The whole tissue bank can undergo ethical review by the REC. This will allow for generic ethical approval status to be given to the biobank for research using banked tissue, addressing the ethical issues upfront without unnecessary repetition. The committee also produces an annual report describing how tissue banked in Scotland was used for research during the year. The issues assessed during ethical review are as follows;
• Quality/content of informed consent / authorisation arrangements
• Arrangements for collection of tissue
• Information about prospective research purposes
• Feedback of clinically significant information
• Policy for researcher access to tissue, any exclusions
• Return of research data to link with banked samples

The practical implications of implementing a biobank represented an organisational challenge for the NHS. They are guardians of tissue and data and have responsibility to ensure functional governance structure, policies, systems and protocols. The main organisational challenge was patient’s authorisation; ensuring all patients have the opportunity to gift their surplus tissues. Key points to establish were how to distribute the patient information, who should seek patient authorisation, when should patients be asked and where should it be recorded. A number of systems were tried and tested before a successful one was found. Firstly, an A4 patent information sheet was produced and issued by Medical Records with appointment letter. The research nurse then asked the patient for authorisation to bank surplus tissue, there was a stand alone consent form to be completed but very limited numbers of tissue being banked. In the second method the surgeon recorded consent for biobank on the ‘consent to anaesthesia’ form. An audit revealed only 5% of patients had been asked for authorisation to gift surplus tissue. Also the information on the ‘consent to anaesthesia’ form had to be manually transferred to pathology request form. The option of asking patients on the ward prior to surgery was explored but the consensus was that this is not the time to ask for authorisation as at this point there are lots of demands on the patient and the main focus is on proposed surgery, risks and post surgical care. At this point, the NHS GGC undertook a system redesign with the use of IT to enable the process. The e-form; Surplus Tissue Authorisation Form (e-STA) was created with a stand alone screen to record patient wishes and withdrawal. The e-STA is completed at the pre-operative assessment clinic. The pre-operative assessment form is also in e-format and the e-STA is tagged onto end of it. Information held is stored electronically and can be accessed by Pathology and Bio-repository to confirm patients’ wishes. An audit of the new system revealed out of 783 patients 97.4% gave authorisation for biobanking. However a further organisational challenge remains that NHS R&D activity is not an immediate priority for staff at clinical ‘coal face’. More recently a tissue banking supporting policy “Better Cancer Care: An Action Plan” (2008) lead to roll out of e-STA form to other hospitals and national collections of renal and colorectal tissue for bio-banking. Gifting tissue for research is critical for molecular & genetic epidemiology, molecular pathology and pharmacogenetics and will ultimately lead to better diagnostics, better drugs and better outcomes.

Terry Coaker, Histopathology Operations Manager, Cellular Pathology, Royal Victoria Infirmary, Newcastle shared his experiences on ‘Lean transformation; finding the balance between tools and people.’ In 1981, the Cellular Pathology department in the Royal Victoria Infirmary processed 9,700 requests per annum, in 2009 after numerous amalgamations with other histopathology laboratories requests had increased to 47,000 per annum. In 2007, the department had introduced lean tools to the examination processes in the laboratory environment and in 2009 the pre-examination phase underwent lean transformation. Drivers for change included the Lord Carter report, pressure to modernise scientific careers, pressure from private sector and to reduce costs, NHS modernisation and to improve the service. The NHS improvement website contains some useful reports on improvement processes in histopathology and cytopathology laboratories, see links;
 http://clinicalcytology.co.uk/resources/pdf/14dayturnaround.pdf
 http://system.improvement.nhs.uk/ImprovementSystem/ViewDocument.aspx?pat...
 http://system.improvement.nhs.uk/ImprovementSystem/ViewDocument.aspx?pat...

The lean process must keep a technical balance between ‘technical’ (tools) and ‘cultural’ (people) processes to work. Too much technical leads to some processes becoming more efficient with lean belonging to a few enthusiasts but failing to be embedded in departmental culture and there is a resistance to change leading to results not being sustained and no overall transformation. Too much emphasis on culture creates a temporary feel good factor with better teamwork and increased levels of involvement but is hard to sustain without results. Lack of rigour in use of tools leads to failure to establish flow, lean “speak” without true understanding and the full potential of lean is not realised. Staff engagement is central to making lean transformation a success so visual display and daily meetings (huddle) were the main forms of communication at this department. A successful lean leader must not manage from the office but go and see, ask why, respect people and force reflection. Each ‘bench’ has a daily huddle with weekly huddle review and monthly histology performance meetings. Benefits of daily huddle are that it addresses issues immediately, clarifies duties, encourages feedback, staff know more about their role, have ownership of the process and the meetings are motivating and enjoyable! Visual displays take time and effort to make them functional and easy to read but are worthwhile as they are very effective. A3 problem solving process is also used to address issues; the problem is discussed and recorded using one side of A3 paper and pencil and eraser, root cause analysis is performed asking five why questions. Actions; plan, do, check and act are carried out. Further issues include that finding no problems is a problem, discipline and poor performance must be addressed outside the huddle.

Gemba audit is a more advanced lean tool and has been a new development in the department when issues remain unresolved or are not seen as the number one priority. This often happens if there is a lack of time to investigate and fix or superficial solutions are used (sticking plasters are not ‘root cause’). Other issues where gemba audits were used include if there is no clear ownership, med / tech barrier blocks communication, or when performance was not reviewed (no huddle). Some actions that arose from Gemba audits to address problem were as follows; open issues and outstanding CAPA’s discuss at histo performance meeting, add “waste walks” to performance indicators, define checklist of Gemba audits, define dashboard for audit design audit visual display boards. Gemba audits result in robust gathering of problems and speedy and binding resolution of issues.

The next presentation was from Allan Kennedy, Lead Biomedical Scientist, Molecular Pathology, Glasgow Royal Infirmary, titled; FISH in Pathology – Applications, Answers and More. The Molecular Pathology department at Glasgow Royal Infirmary perform FISH testing on tissue imprints, blood and FFPE tissue for Her2 breast carcinoma, lymphomas and sarcomas and oligodendroglial tumours. The FISH technique has five main steps; access the target, denature, hybridise, counterstain and view the result. The types of probes used include enumeration probes for loss or amplification of a gene or chromosome, break-apart probes to target a specific gene and dual fusion probes to detect a specific chromosome translocation. Examples of enumeration probes used are Her2 which can be detected as amplified or non-amplified by FISH. This test can also show chromosome 17 polysomy which can lead to increased copes of Her2 gene. In chronic lymphocytic leukaemia an enumeration probe for P53 (17p13.1) and ATM (11q22.3) is used in FISH testing. Loss of ATM is associated with progressive disease. Loss of P53 is associated with progressive disease and Fludarabine resistance. In lymphomas, dual colour fusion probes t8:14, t11:14 and t14:18 are used to characterise the tumour as well as the C-Myc(8q24) break-apart probe. The following paediatric sarcomas contain chromosome translocations which are specific for the tumour type some of which can provide prognostic as well as diagnostic information; ewing/PNET - t(11;22)(q24;q12) and t(21;22)(q22;q12), alveolar rhabdomyosarcoma - t(2;13)(q35;q14) and t(1;13)(p36;q14), desmoplastic small round cell tumor - t(11;22)(p13;q12), synovial sarcoma - t(X;18)(p11.2;q11.2), congenital fibrosarcoma - t(12;15)(p13;q25) and clear cell sarcoma - t(12;22)(q13;q12). FISH techniques require a high level of expertise, some guidelines recommended by this department are; the need to record all observations-whether expected or not and the need for close co-operation with Pathologists. As molecular pathology develops, collaboration across centres is pivotal to success, the boundaries between Pathology, Genetics and Haematology are rapidly blurring.

Dr. Dave Baty, Head of Molecular Genetics Laboratory, Ninewells Hospital, Tayside NHS, Dundee presented Genetics and Pathology, what can they do for each other? In Scotland, the nationally funded NHS genetic service consisting of a four centre consortium covering genetics service responsible for a wide range of inherited genetic conditions. Dr Baty predicts that the future workload of genetics will increasingly be molecular pathology/diagnostic tests. Changes at the chromosome and DNA level will aid diagnosis, determine outcome and define treatment pathways. Partnership with Pathology is crucial for effective delivery of molecular diagnostic tests and there is an excellent relationship between Pathology and Genetics in Tayside NHS.

A good example of how genetics and pathology can work together for inherited cancer is Lynch syndrome. Familial colorectal cancer syndrome is characterised by hundreds of colorectal polyps as well as extra-colonic tumours. It is important to distinguish families at high risk of Lynch syndrome from sporadic disease. This can be done through combination of genetic techniques and IHC on tumour sections which allows targeted testing of tumours for MMR defects. Some genetic testing for cancer is diagnostic (IgH & TCR gene rearrangements, MSI, BRAF p.V600E) and prognostic (KRAS, cKIT / PDGFR, Her2). The presence of a mutation in KRAS in colorectal cancer or a cKIT / PDGFRA mutation in GIST can have significant implications for treatment. Approximately 30-50% of colorectal tumours have a KRAS mutation at 3 codons in gene. Tumours with a mutation will not respond to a specific class of treatment. It is important for patients to know what the mutation status of their tumour is. For KRAS testing, it is crucial to get good quality tissue sections and to know the tumour load. 85-90% of GISTs have activating mutations in cKIT or PDGFRA. The position of the mutation can influence how the tumour will respond to specific treatment.

Genetics and Pathology working together will gain a shared expertise, skills and capital equipment, opportunities for integrated training at various career levels, opportunity to develop specialist teams and shared R&D. Collaborative working is the only way of delivering Molecular Pathology/Diagnostics. Working together will future proof both disciplines and ultimately provide the best service to patients.

Kevin Pollock, Senior Epidemiologist at Health Protection Scotland discussed Zoonoses; using epidemiological tools to study virulence and aetiology. Core activities of Health Protection Scotland (HPS) include surveillance, operational support, research, education and production of guidance. Zoonoses are infectious agents transmitted from vertebrate animals to humans, 75% of emerging pathogens are zoonotic e.g. SARS, E. coli O157. They may be affected by man’s management of the environment and include Campylobacter, Salmonella, Cryptosporidium, E. coli O157 and Q fever.

Cryptospodidium infection causes profuse diarrhoea, bloating, abdominal pain, nausea and may lead to reactive arthritis. It can be potentially fatal in immuno-compromised individuals. Confirmation of infection is by isolation of oocysts in stool samples. Epidemiology of Cryptosporidium is as follows; C. parvum and C. hominis predominate, C. parvum is associated with zoonoses/pws, C. hominis with foreign travel/urban, can be transmitted by person-to-person contact. The genus is resistant to disinfection therefore can be present in swimming pools and private and/or public water supplies. Low-level exposure to oocysts via unfiltered water might result in a higher background level of immunity to Cryptosporidium among Glasgow consumers. Exposure may stimulate a protective effect among people subsequently exposed to Cryptosporidium from other sources. Consequence of introducing filtration water supplies might therefore reduce the level of ‘herd immunity’ to Cryptosporidium in the relevant population. Ser-epidemiological studies have shown donors with pets had a lower serological response to Crypto than those without pets, serological responses increased for swimmers and if on a private water supply and decreased if drinking bottled water.

Predominantly E.coli O157 infection is the main problem (UK and ROI, North USA), but non-O157 serotypes are also in important in certain countries (Australia, Germany). E.coli infection caused by cattle/livestock/humans faeces. Causes abdominal cramps, bloody diarrhoea, develops into HUS in 10-15% of cases. Medications are either neutral or contra-indicated. In 50% of cases the cause of transmission is unknown. Higher incidence from farm contact, can be person-person spread, food is common as source of infection and/or private water supplies. Q fever is transmitted primarily by cattle, sheep and goats. Disease ranges from asymptomatic to fatal chronic endocarditis. It is listed by CDC as a bio-terrorism agent, several cases reported to HPS per year.
Zoonoses infection is on the increase because of better surveillance/lab practices, more ready to eat foods with reduced salt content, a reluctance to throw out food increased ownership of diverse pets, an ageing population, an immunologically naïve population and improved hygiene.

Naomi Cronin
AMLS Cellular Pathology Advisory Body (Chair)