QUALITY IMPROVEMENT IN DIAGNOSTIC
HEMATOPATHOLOGY: AN INTEGRATION OF HUMAN
RESOURCES AND OF ADVANCING TECHNOLOGIES
M. MARINO
Dept. of Pathology
REGINA ELENA NATIONAL CANCER INSTITUTE
Rome, Italy
Management in Anatomia Patologica:
Quale rischio?
Rome, October 22-24, 2009
Hematopathology is considered a subspeciality of
Pathology requiring routine use of ancillary
techniques such as immunohistochemistry in
order to set a diagnostic updated evaluation of
lymphoproliferative and myeloproliferative
disorders
Molecular biological methods and viral status are
actually required in some cases in order to reach
a diagnosis
The WHO classification both in 2001
and with the 2008 update clearly
definied lymphoma entities basing on
morphological, immunophenotypical,
genetical and clinical data
OUR CASES
IN THE YEARS 2001-2009, ABOUT 600 FIRST LYMPHOMA
DIAGNOSES OR SECOND OPINION EVALUATION HAVE BEEN DONE
CHRONIC LYMPHOPROLIFERATIVE DISORDERS AND MULTIPLE
MYELOMA CASES ARE ALSO FREQUENTLY DIAGNOSED
MOST OF THE PATIENTS ARE FOLLOWED AT THE INSTITUTE, THUS
ALLOWING AN EVALUATION OF THE DISEASE OVER THE YEARS
Disease Management Team (DMT) meetings as a
quality procedure
Experience at the Regina Elena National Cancer Institute,
Rome
Multidisciplinary team (pathologist / hematologists/ radiologist / radiotherapist /
Cytofluorimetry specialist / Cytogenetist as permanent components)
Psychologist / neurologist / surgeons / dermatologists / nuclear medicine
Weekly meetings
Discussion of every new case and during follow up
Therapeutical decisions
In Clinical Pathology, extensive characterization of lymphoid
populations was obtained by flowcytometry analysis
In Clinical Pathology Fluorescent In Situ Hybridization (FISH)
cytogenetic analysis of bone marrow and, in the Pathology
Department, of formalin-fixed, paraffin embedded tissue was
established for the major chromosomal aberrations in lymphoma.
Clonality studies in lymphoma diagnosis for both B- and T-cell
proliferation have been established in the Pathology Dept.by
capillary electrophoresis analysis of PCR products by using the
BIOMED-2 protocol
QUALITY CONTROL IN HEMATOPATHOLOGY
1)Second interinstitutional review
2)Second pathology review
3)Continuous medical education
SECOND REVIEW
Interinstitutional second review is a spontaneous and traditional
method to verify and validate hematopathological diagnoses
The second review derives:
1) From a spontaneous choise of the pathologist dealing with
difficult or controversial cases (for example, discordant
diagnosis with a previous pathologist)
2) From the clinical’s request of a second opinion in a
national/international reference center
3) From the patient request
Cases
Among about 600 new lymphoma diagnoses in the years
2001-2009, 45 cases (about 7.5%) have been review in the
Reference center listed
Some few cases directly sent from the patient could be
missing to this review if not later reported to the clinicians or
to the pathologist
Reference centers involved
1) Hematopathology Unit, Policlinico S. Orsola, Bologna (Prof. S.
Pileri)
2) Dept. Of Pathology, University of Wuerzburg, Germany (Prof.
HK Mueller-Hermelink
3) Centro Oncologico di Aviano (Dr Canzonieri)
4) S. Giovanni Rotondo, Casa Sollievo della Sofferenza (Dr M.
Bisceglie)
33 cases out of 45 received the same diagnosis
1) DLBL
7 cases
2) ALCL
1 case
3) MZL
5 cases
4) FL
3 cases
5) BL
1 case
6) AILD
2 cases
7) NK
1 case
7) T-Lb
1 case
8) FDCS
1 case
9) HL
6 cases
10) Inflammatory
3 cases
11) Negative for lymph.
1 case
12) Insufficient material
1 case
A discordant diagnosis was received in 10 cases
Problem analysis
1) Overevaluation of normal nodular mucosal pattern / no molecular data
1
2) Underevaluation of nodular pattern/no sufficient immunohistochemical study
1
3) Overevaluation of monotonous Follicles / molecular data pointed to the correct
diagnosis
1
4) Misinterpretation of large atypical cells
1
5) Suspicious PTCL vs T cell area hyperplasia/ T cell lymphoma vs blastoid phase Kikuchi
lymphadenitis (1 case without molecular data, 1 with)
2
6) PTCL underevaluated as necrotizing lymphadenitis
1
7) PCNS B-Lb vs BL; T-Lb vs AILD (misinterpretation of Tdt results)
2
8) Underevaluation of a focal involvement by HL
1
2 ADDITIONAL CASES OF EXCEPTIONAL DIAGNOSTIC
DIFFICULTY HAVE ALSO BEEN SENT, AND
EVALUATED ONLY AT THE REFERENCE CENTER
Appropriate use of ancillary and molecular
biological methods require experience and
knowledge of limits of each technique
S. Conti , R. Covello , F. Marandino, S. Sioletic,
S. Buglioni , G. Chichierchia, R. Martucci,
P. Canalini, A. Papadantonakis, E. Gallo, B. Antoniani
R. Perrone Donnorso
Dept. Of Pathology
F. Pisani, L. Dessanti, M. D’Andrea, M.C. Petti
Hematology
R.Merola, I. Cordone
Clinical Pathology