AP checklist Flashcards
ANP.08216, Formaldehyde/Xylene Safety
“Formaldehyde and xylene vapor concentrations are maintained below the following maxima, expressed as parts per million, in all areas of the Anatomic Pathology Department where formaldehyde or xylene are used., NOTE: Formaldehyde and xylene vapor concentrations must be monitored in all areas where these reagents are used: e.g. surgical pathology gross dissection room, frozen section area, histology laboratory, autopsy room, etc. Xylene vapor concentration monitoring in histology laboratories should include manual and automated coverslipping areas, as these locations are often not ventilated. Initial monitoring involves identifying all employees who may be exposed at or above the action level or at or above the STEL and accurately determining the exposure of each employee identified. Further formaldehyde monitoring is mandated at least every 6 months if results of the initial monitoring equal or exceed 0.5 ppm (8 hr time-weighted exposure, the “action level”) or at least once per year if the results exceed the short term exposure limit (STEL) 2.0 ppm. The laboratory may discontinue periodic formaldehyde monitoring if results from 2 consecutive sampling periods taken at least 7 days apart show that employee exposure is below the action level and the short-term exposure limit, and 1) no change has occurred in production, equipment, process or personnel or control measures that may result in new or additional exposure to formaldehyde, and 2) there have been no reports of conditions that may be associated with formaldehyde exposure.
Formaldehyde monitoring must be repeated any time there is a change in production, equipment, process, personnel, or control measures which may result in new or additional exposure to formaldehyde for any employee involved in the activity. If any personnel report signs or symptoms of respiratory or dermal conditions associated with formaldehyde exposure, the laboratory must promptly monitor the affected person’s exposure.
Xylene must be monitored initially, but there is no requirement for periodic monitoring of xylene. Repeat monitoring should be considered when there is a change in production, equipment, process, personnel, or control measures likely to increase exposure levels., “
ANP.10016, Surgical Pathology Exclusion
“There is a policy that lists specimens that an institution may choose to exclude from routine submission to the pathology department for examination. , NOTE: This policy should be made in conjunction with the hospital administration and appropriate medical staff departments. The laboratory director should have participated in or been consulted by the medical staff in deciding which surgical specimens are to be sent to the pathology department for examination.
This checklist item is not applicable if 1) all specimens are submitted to pathology, or 2) the laboratory is not part of an institution that provides surgical services., “
ANP.10032, Surgical Pathology Microscopic Exemptions
There is a policy regarding what types of surgical specimens (if any) may be exempt from microscopic examination., NOTE: Irrespective of any exemptions, microscopic examination should be performed whenever there is a request by the attending physician, or at the discretion of the pathologist when indicated by the clinical history or gross findings. If there is such a policy, it should be approved by the medical staff or appropriate committee. Typical exempt specimens include foreskins in children, prosthetic cardiac valves without attached tissue, torn meniscus, varicose veins, tonsils in children below a certain age, etc.,
ANP.10050, Previous/Current Material Review
Whenever appropriate, pertinent previous cytologic and/or histologic material from the patient is reviewed with current material being examined., NOTE: Because sequential analysis of cytologic and histologic specimens may be critical in patient management and follow-up, efforts must be made to routinely review pertinent previous material. Documentation of the retrospective review should be included in the current patient report.,
ANP.10100, Intra-operative/Final Diagnosis Disparity
When significant disparity exists between initial intra-operative consultation (e.g. frozen section, intra-operative cytology, gross evaluation) and final pathology diagnosis, it is reconciled and documented in the surgical pathology report and in the departmental quality management file., ,
ANP.10150, Intra and Extra-Departmental Consultations
“The laboratory has a policy for handling intra- and extra-departmental consultations in the patient’s final report., NOTE: Intra-departmental consultations may be included in the patient’s final report, or filed separately. The pathologist in charge of the surgical pathology case must decide whether the results of intra-departmental consultations provide relevant information for inclusion in some manner in the patient’s report.
Documentation of extra-departmental consultations must be readily accessible within the pathology department. The method used to satisfy this requirement is at the discretion of the laboratory director, and can be expected to vary according to the organization of the department. These consultations can be maintained with the official surgical pathology reports or kept separately, so long as they can be readily linked., “
ANP.10250, Extra-Departmental Consultation
When extra-departmental cases are submitted to the laboratory for consultation, they are accessioned according to the standard practices of the laboratory, and a documented report is prepared, with a copy sent to the originating laboratory., NOTE: In most cases, original materials including slides and blocks should be promptly returned to the original institution. However, in some situations (for example, when the patient is receiving ongoing care at the referral institution pending tumor resection, etc.) it may be appropriate for the referral laboratory to retain slides/blocks for a period of time. In such situations, a letter should be sent to the originating laboratory along with the consultation report, requesting permission to retain the slides/blocks and accepting transfer of stewardship of the patient materials from the original laboratory to the referral institution.,
ANP.10255, Professional Competency
The laboratory director ensures the professional competency of pathologists who provide interpretive services to the anatomic pathology laboratory., NOTE: The mechanism for competency assessment must be pertinent to the type of interpretive services provided. There must be a written policy for assessing professional competency, criteria for the assessment, and records of the assessment must demonstrate review by the laboratory director.,
ANP.10260, Slide/Block Handling
There is a policy defining the handling of original slides/blocks for consultation and legal proceedings., NOTE: This must include appropriate handling and documentation of the use, circulation, referral, transfer, and receipt of original slides and blocks. The laboratory must have a record of the location of original slides and blocks that have been referred for consultation or legal proceedings.,
ANP.10270, Off-Site Autopsies
As applicable, there is a policy for performance of autopsies off-site., NOTE: If feasible, the autopsy room should be located within the institution. Requirements in the Autopsy Pathology section that relate to the physical facility, dissection and handling of organs and tissues apply only to those cases that are performed at the site under CAP accreditation. The pathologist should encourage off-site locations where autopsies are performed (e.g. Funeral homes) to provide facilities that meet the standards expected for accredited autopsy rooms.,
ANP.11250, Adequate Storage
Refrigerated storage is available for large or unfixed specimens., ,
ANP.11275, Radioactive Material Handling
“There are specific policies and procedures for the safe handling of tissues that may contain radioactive material (e.g. sentinel lymph nodes, breast biopsies, prostate ““seeds,”” etc.)., NOTE: These procedures should be developed in conjunction with the institutional radiation safety officer, and must comply with any state regulations for the safe handling of tissues containing radionuclides. The policy should distinguish between low radioactivity specimens such as sentinel lymphadenectomy and implant devices with higher radiation levels.
The pathology department may wish to monitor these specimens for radioactivity, with safe storage of specimens until sufficient decaying has occurred, before proceeding with processing in the histology laboratory. , “
ANP.11475, Sub-Optimal Specimens
There are documented procedures for handling sub-optimal specimens (e.g. specimens that are unlabeled, not labeled with two patient identifiers on the container, unaccompanied by adequate requisition information, left unfixed or unrefrigerated for an extended period, received in a container/bag with a contaminated outside surface)., ,
ANP.11500, Specimen Identity
The identity of every specimen is maintained at all times during the processing and examination steps., ,
ANP.11525, Tissue/Cytology Assessment Record
If a statement of adequacy, preliminary diagnosis, or recommendations for additional studies is provided at the time of tissue and cytology sample collection, documentation of that statement is maintained., NOTE: Documentation might include a note in the medical record or in the final report.,
ANP.11550, Specimen Retention
Gross specimens are retained until at least 2 weeks after the final reports are signed and results reported to the referring physician., ,
ANP.11600, Gross Examination - Pathologist
All macroscopic tissue gross examinations are performed by a pathologist or pathology resident, or under the supervision of a qualified pathologist., NOTE: Specific requirements for supervision of non-pathologists who assist in grossing specimens, are given below.,
ANP.11605, Gross Examination - Non-Pathologist
When individuals other than a pathologist or pathology resident assist in gross examinations, the extent of their activities and the nature of supervision (direct vs. indirect) is defined in a documented protocol., NOTE: This protocol must list the specific types of specimens for which non-pathologists are permitted to assist in the gross examination. The nature of the supervision must be established individually, for each non-pathologist. The laboratory director is responsible for this protocol. For Mohs surgery a dermatologist is also qualified to perform the gross examination and to supervise non-pathologists.,
ANP.11610, Gross Examination Qualifications
“If individuals other than a pathologist or pathology resident assist in gross examinations, such individuals qualify as high complexity testing personnel under CLIA regulations., NOTE: The laboratory director may delegate the dissection of specimens to non-pathologist individuals; these individuals must be qualified as high complexity testing personnel under CLIA regulations. The minimum training/experience required of such personnel is:
- An earned associate degree in a laboratory science or medical laboratory technology, obtained from an accredited institution, OR
- Education/training equivalent to the above that includes at least 60 semester hours or equivalent from an accredited institution. This education must include 24 semester hours of medical laboratory technology courses, OR 24 semester hours of science courses that includes 6 semester hours of chemistry, 6 semester hours of biology, and 12 semester hours of chemistry, biology or medical laboratory technology in any combination. In addition, the individual must have laboratory training including either completion of a clinical laboratory training program approved or accredited by the ABHES, NAACLA, or other organization approved by HHS (note that this training may be included in the 60 semester hours listed above), OR at least 3 months documented laboratory training in each specialty in which the individual performs high complexity testing.
It is the responsibility of the laboratory director to determine whether an individual’s education, training and experience satisfies the requirements of this checklist requirement.
This checklist requirement applies only to laboratories subject to US regulations., “
ANP.11640, Competency Assessment of Non-Pathologists
“The competency of non-pathologist(s) who assist in the performance of gross tissue examinations is assessed by the pathologist at least annually., NOTE: Please refer to GEN.55500, Competency Assessment, in the Laboratory General checklist for a list of criteria and frequency for competency assessment. Not all six elements may apply in all cases.
For Mohs surgery a dermatologist is also qualified to perform the gross examination and evaluate non-pathologists., “
ANP.11650, Mohs Diagnosis
Mohs surgically excised tissue diagnoses are made by a dermatologist, dermatopathologist, or pathologist., NOTE: The diagnosis includes whether or not tumor is present, assessment of the margins, etc.,
ANP.11660, Pathologist Diagnosis
All surgical tissue diagnoses are made by a pathologist., ,
ANP.11670, Specimen - Gross Examination
Documented instructions or guidelines are readily available in the laboratory for the proper dissection, description, and histologic sampling of various specimen types (e.g. mastectomy, colectomy, hysterectomy, renal biopsy, etc.)., NOTE: The guidelines should address large or complicated specimen types and smaller specimens requiring special handling, such as muscle biopsies, renal biopsies, and rectal suction biopsies for Hirschsprung’s disease. Guidelines serve an important educational function in departments with postgraduate (residency) programs. However, they also are useful in providing consistency in the handling of similar specimen types in departments without such training programs.,
ANP.11713, Histologic Prep Quality
“There is documented evidence of daily review of the technical quality of histologic preparations by the pathologist or designee., NOTE: If specimens are referred to an outside laboratory for histologic processing, there must be a procedure for providing feedback on slide quality to the outside laboratory.
This checklist requirement is intended to apply to routine histology slides. Specific quality control requirements for special stains, immunohistochemistry, and other special studies are found elsewhere in this checklist., “
ANP.11716, Paraffin Microtomy
There is a written procedure that indicates the sectioning thickness of paraffin embedded tissue for various tissue types and procedures., NOTE: Paraffin embedded sections are routinely sectioned at 4-5 microns. Some tissues (e.g. renal biopsy) may require thinner sections, while some special stain techniques (e.g. congo red stain) may require thicker sections. Use of the recommendations in the table below is at the discretion of the laboratory director.,
ANP.11734, Slide Quality
Slides are of sufficient quality for diagnosis., NOTE: Histopathology slides must be of adequate technical quality to be diagnostically useful. Criteria to evaluate include adequate tissue fixation, processing, thickness of sections, absence of interfering tissue folds and tears, and good staining technique and cover slipping. For hematoxylin and eosin and other routine stains, the patient slide serves as the internal control to ensure adequate staining technique. The sections must be cut from sufficient depth in the block to include the entire tissue plane.,
ANP.11756, Reagents
All solutions and stains are properly labeled and changed on a defined schedule., NOTE: All solutions and stains must be properly labeled with the contents, and, if applicable, date they are changed/filtered and expiration date. All solutions and stains should be changed or filtered following a defined process, determined by the usage of the reagents.,
ANP.11800, Intra-Operative Slide/Container Labeling
Each slide and container used to submit residual tissue for routine processing is labeled with two identifiers., NOTE: Acceptable patient identifiers include name, date of birth, medical record, and accession number.,
ANP.11810, Frozen Section Preparation Quality
Frozen section, touch and scrape preparations are adequate for intra-operative diagnosis., ,
ANP.11850, Intra-Operative Results
The results of intra-operative surgical consultations are documented and signed by the individual who made the diagnosis., NOTE: The intent of this requirement is for the laboratory to maintain a contemporaneous report of the consultation. This may be a handwritten, signed report or a computer-generated report with electronic signature. ,
ANP.11900, Verbal Reports
If verbal reports are given, the pathologist is able to speak directly with intra-operative medical/surgical personnel., ,
ANP.11950, Verbal Report/Patient ID
The patient’s identification is checked and confirmed before delivery of any verbal report., ,
The patient’s identification is checked and confirmed before delivery of any verbal report., ,
The patient’s identification is checked and confirmed before delivery of any verbal report., ,
ANP.12050, Frozen Section Slides
All frozen section, touch and scrape preparation slides are permanently stained, mounted, properly labeled, and retained with the rest of the slides from the case., ,
ANP.12075, Residual Frozen Tissue
“Following frozen section examination, the residual frozen tissue is routinely processed into paraffin, and a histologic section prepared and examined for comparison with the frozen section interpretation., NOTE: The laboratory must prepare a paraffin block and stained slide(s) from each frozen section block, and such paraffin blocks must be retained in accordance with CAP guideline for retention of surgical pathology blocks (ANP.12500).
Correlation of frozen section findings with a permanent section prepared from routinely fixed and processed residual frozen tissue is an important quality improvement mechanism. Evaluation of such permanent sections provides important feedback on the accuracy of frozen section diagnoses and improves recognition of specific frozen section morphologic alterations.
The only exceptions to this requirement are as follows: 1) Frozen tissue that must be submitted for specialized studies; 2) Mohs frozen sections. However, the CAP strongly recommends preparation of paraffin sections from frozen tissue used for Mohs frozen sections, for quality management purposes. CAP also recommends retention of the tissue used for Mohs frozen sections in accordance with CAP retention guidelines., “
ANP.12092, FNA Specimen Labeling
If the pathologist performs FNA procedures or if laboratory personnel participate in FNA procedures, two patient identifiers are placed on the prepared slides and any specimen container at the time of the procedure., NOTE: All specimens must be labeled at the time of collection to provide unique identification. Each prepared slide must be labeled separately and any specimen container with collected material (e.g. fluid from aspiration) must also be labeled.,
ANP.12094, Error Prevention Patient ID
If the pathologist performs FNA procedures, there is a documented procedure to assure proper identification of the patient, the site and the procedure. , ,
ANP.12096, FNA Cross Contamination
There is a procedure to prevent cross contamination of FNA specimens during processing and staining., NOTE: Methods to minimize this problem may include cytocentrifuge, filter and monolayer preparations. Smears made from highly cellular cases should be stained after the other cases, and the staining fluids must be changed or filtered between each of the highly cellular cases. One procedure to detect contamination is to insert a clean blank slide in each staining run and examine it for contaminating cells.,
ANP.12170, Report Review
All reports are reviewed and signed by the pathologist., NOTE: The inspector must review a broad sampling of surgical pathology reports issued since the previous on-site inspection, representing at least the most common types of specimens seen in the laboratory. When diagnostic reports are generated by computer or telecommunications equipment, the actual signature or initials of the pathologist may not appear on the report. It is nevertheless essential that the laboratory have a procedure that ensures and documents that the responsible pathologist has reviewed and approved the completed report before its release. In the occasional situation when the diagnosing pathologist is not available for timely review and approval of the completed report, the laboratory may have a policy and procedure for review and approval of that report by another pathologist. In that circumstance, the names and responsibilities of both the pathologist who made the diagnosis and the pathologist who performs final verification must appear on the report.,
ANP.12173, Mohs Report
There is a written report generated for each Mohs surgical procedure., NOTE: A written note, report, or diagram must be included in the patient’s medical record or operative report. The report should include required elements such as gross description, accession number, designation of relationship of blocks to the slides, and clear diagnosis on each specimen.,
ANP.12175, Significant/Unexpected Findings
“There is a policy regarding the communication, and documentation thereof, of significant and unexpected surgical pathology findings., NOTE: Certain surgical pathology diagnoses may be considered significant and unexpected. Such diagnoses may include: malignancy in an uncommon location or specimen type (e.g. hernia sac, intervertebral disk material, tonsil, etc.), or change of a frozen section diagnosis after review of permanent sections. There should be a reasonable effort to ensure that such diagnoses are received by the clinician, by means of telephone, pager or other system of notification. There must be documentation of the date of communication of these diagnoses.
The pathology department may designate certain surgical pathology diagnoses for prompt communication to the clinician. Such diagnoses may include, for example, neoplasms causing paralysis, or fat in an endometrial curettage. There must be documentation of the date of communication of such results.
Diagnoses to be defined as “significant and unexpected,” and those for prompt communication should be determined by the pathology department, in cooperation with local clinical medical staff.
Documentation of communication of these diagnoses may be included in the pathology report, or in other laboratory records.
This requirement takes the place of critical result notification in the All Common Checklist (COM.30000 and COM.30100)., “
ANP.12185, Amended Reports
Amendments to reports that would significantly affect patient care are reported promptly to the responsible clinician(s)., NOTE: Records of notification should include date, time, and person notified, and preferably appear in the amended report. Periodic evaluation of amended reports is commonly included as part of the quality management program.,
ANP.12200, Gross Description Reporting
“All surgical pathology reports include gross descriptions, information essential for diagnosis and patient care, and record-essential processing information., NOTES:
- Descriptions should include information regarding type, number, dimensions and/or weight of specimens, measurements and extent of gross lesions
- Processing information should include a summary of block/slide designations for special sections as appropriate (e.g. margins of resection, breast quadrants, lymph node levels, etc.)
- Annotated drawings and photographs are valuable tools for documenting gross findings, but are not adequate replacements for a text description, “
ANP.12350, Cancer Protocols
“All data elements required in applicable CAP Cancer Protocols are included in the surgical pathology report., NOTE:
- The use of these protocols is encouraged, but not required, providing that the data elements required by the protocols are present in the report.
- Data elements not applicable to the specimen need not be included in the report. (For example, if a mastectomy specimen does not include lymph nodes, no reference to lymph nodes is required.)
- This checklist requirement is not applicable to cancer reports for which no CAP Cancer Protocol applies (for example, incisional biopsy of the breast) nor to reports on specimens that do not contain cancer.
- Reports must include the required data elements from the current edition of the CAP Cancer Protocols. Laboratories may use the previous edition of the Protocols for up to 8 months after publication of the current edition.
This checklist requirement should be cited by the inspector only if there is a pattern of repeated failure to include all requirements in multiple reports., “
ANP.12385, Synoptic Reporting
“Data elements required by applicable CAP Cancer Protocols are reported using a synoptic format., NOTE:
1 All required cancer data from an applicable cancer protocol that are included in the report must be displayed using a format consisting of the required checklist item (required data element), followed by its answer (response), e.g. ““Tumor size 5.5 cm.”” Outline format without the paired required data element (RDE): response format is not considered synoptic.
2 Each diagnostic parameter pair (checklist RDE: response) is listed on a separate line or in a tabular format, to achieve visual separation. For example:
- Headers may be used to separate or group data elements
- Any line may be indented to visually group related data elements or indicate a subordinate relationship
- Text attributes (e.g. color, bold, font, size, capitalization/case, or animations) are optional
- Blank lines may be used to separate data elements and group related elements
Note: the following are allowed to be combined on the same line:
- Anatomic site or specimen, laterality and procedure
- Pathologic Staging Tumor Node Metastasis (pTNM) staging elements
- Negative margins, as long as all negative margins are specifically enumerated
- If multiple responses are permitted for the same data element, the responses may be listed on a single line.
- The synopsis can appear in the diagnosis section of the pathology report, at the end of the report or in a separate section, but all RDE and responses must be listed together in one location.
- Additional items (not required for the CAP checklist) may be included in the synopsis but all required RDE must be present.
- Narrative style comments are permitted in addition to, but are not as a substitute for, the synoptic reporting. It is not uncommon for narrative style comments to be used for clinical history, gross descriptions and microscopic descriptions., “
ANP.12400, Correlation of Results
There is a mechanism to correlate the results of specialized studies (e.g. immunohistochemistry, nucleic acid probes, cytogenetics, flow cytometry, electron microscopy) with the morphologic diagnosis., NOTE: It is not in the best interests of the patient to have potentially conflicting diagnoses or interpretations rendered by different sections of the laboratory. The pathologist should issue a report reconciling potentially conflicting data, when appropriate.,
ANP.12425, ASR Disclaimer
“If patient testing is performed using Class I analyte-specific reagents (ASRs) obtained or purchased from an outside vendor, the patient report includes the disclaimer required by federal regulations., NOTE: ASRs are antibodies, both polyclonal and monoclonal, specific receptor proteins, ligands, nucleic acid sequences, and similar reagents which, through specific binding or chemical reaction with substances in a specimen, are intended for use in a diagnostic application for identification and quantification of an individual chemical substance or ligand in biological specimens.
By definition, an ASR is the active ingredient of a laboratory-developed test system. ASRs may be obtained from outside vendors or synthesized in-house. ASRs from outside vendors are supplied individually. They are not bundled with other materials in kit form, and the accompanying product literature does not include any claims with respect to use or performance of the reagent.
Class I ASRs in use in the anatomic pathology laboratory include some antibodies for immunohistochemistry and nucleic acid probes for FISH and ISH.
Class I ASRs are not subject to preclearance by the US Food and Drug Administration or to special controls by FDA. Thus, if the laboratory performs patient testing using Class I ASRs obtained or purchased from an outside vendor, federal regulations require that the following disclaimer accompany the test result on the patient report:
"”This test was developed and its performance characteristics determined by (laboratory name). It has not been cleared or approved by the US Food and Drug Administration.””
The CAP recommends additional language, such as ““FDA does not require this test to go through premarket FDA review. This test is used for clinical purposes. It should not be regarded as investigational or for research. This laboratory is certified under the Clinical Laboratory Improvement Amendments (CLIA) as qualified to perform high complexity clinical laboratory testing.””
The above disclaimer is not required when using reagents that are sold in kit form with other materials and/or an instrument, and/or with instructions for use, and/or when labeled by the manufacturer as Class I for in vitro diagnostic use (IVD), Class II IVD, or Class III IVD.
Most antibodies used in immunohistochemistry are labeled “for in vitro diagnostic use” and thus do NOT require the disclaimer.
The laboratory must establish or verify the performance characteristics of tests using Class I ASRs in accordance with the Method Performance Specifications section of the All Common Checklist.
The laboratory may put an ASR disclaimer on the pathology report for all immunostains, FISH and ISH studies collectively used in a particular case. Separately tracking each reagent used for a case and selectively applying the disclaimer to only the class I ASRs is unnecessary. , “
ANP.12500, Record Retention
“Surgical pathology records and materials are retained for an appropriate period., NOTE 1: Minimum requirements for surgical pathology, providing these are not less stringent than local, state and national regulations, are:
- Accession log records - 2 years
- Wet tissue (stock bottle) - 2 weeks after final report
- Paraffin blocks - 10 years (subject to Notes 2 and 3, below)
- Glass slides (including control slides) and reports - 10 years (slides must remain readable for this period)
- Surgical pathology reports - 10 years (see Notes 4 and 5, below)
- Fluorochrome-stained slides - at the discretion of the laboratory director
- Fine needle aspiration slides - 10 years
- Images of FISH studies - 10 years (see Note 6, below)
There must be a documented policy for protecting and preserving the integrity and retrieval of surgical pathology materials and records. The retention period should be extended, when appropriate, to provide documentation for adequate quality control and medical care.
NOTE 2: Regarding extra-institutional release of blocks for research purposes: Federal regulations require that a laboratory retain paraffin blocks for two years unless the tissue is blocked specifically for research and not used for patient diagnostic purposes.* The CAP Commission on Laboratory Accreditation (CLA) requires, however, that paraffin blocks used for patient diagnostic purposes must be kept for at least 10 years. Nevertheless, such blocks may be released for research purposes after the two-year regulatory requirement if all of the following criteria are met:
- For laboratories subject to US regulations, formal written authorization is obtained in accordance with the requirements of HIPAA if identifiable patient information is released.
- The laboratory retains sufficient blocks to support the diagnosis for the full 10-year period.
- Provision is made for retrieval by the laboratory of any blocks or material that remain after use in research, if the blocks or material are needed for diagnostic, legal, or other legitimate purposes.
- The laboratory meets other relevant requirements including but not limited to the requirements of the institution, the directives of any applicable institutional review board (IRB) or similar entity; and state and local laws and regulations.
NOTE 3: Given that patient survival rates are increasing and the continued emergence of treatment based on biomarker testing, which at times may be required on the original tissue, it is recommended that, whenever feasible, tissue block retention from patients with diagnosed malignancies be retained beyond the 10 year requirement.
NOTE 4: Pathology reports may be retained in either paper or electronic format. If retained in electronic format alone, however, the electronic reports must include a secure pathologist electronic signature. Images of paper reports–such as microfiche or PDF files–are acceptable.
NOTE 5: Reports of outside consultations performed on cases from the laboratory (whether or not such consultation was requested by the laboratory) must be retained for 10 years after the date on which the original report was issued.
NOTE 6: There is no retention requirement for images when the source slides remain readable for the required 10-year retention period. The 10-year retention requirement applies to images of slide preparations that are not readable for the 10-year period (e.g. FISH studies).
*The restriction on release of blocks does not prohibit release of blocks for purposes of treatment, diagnosis, prognosis, etc., for patients on research protocols as long as release is consistent with patient privacy regulations (e.g. HIPAA) and applicable state and local regulations; and there is IRB approval, as applicable., “
ANP.21050, Specimen Identity
“The identity of every specimen is maintained through each step of tissue processing and block and slide preparation., NOTE: An unambiguous system of specimen identification coupled with a legible, sequential cassette and slide labeling system that withstands reagents and stains are essential to fulfill this requirement.
Each block of tissue must be identified by the entire accession number assigned to the case and by any descriptive letter(s)/number(s) added by the prosector during the dissection. If additional blocks are prepared later, all lists and logs must reflect these additions. Identification number and letter(s)/numbers(s) must be affixed to all blocks in a manner that remains legible.
Each slide must be identified by the entire accession number and descriptive letters unique to the block from which it is cut. Other appropriate identifiers should be included as applicable (e.g. levels of sectioning). Automated prelabeling systems are acceptable. Regardless of whether the identifying information is on the slide or on a label, the information must be indelible, legible and able to withstand all stages of processing and conditions of storage., “
ANP.21350, Specimen Preparation Records
The histology laboratory maintains records of the number of blocks, slides, and stains prepared., NOTE: Laboratories must be capable of demonstrating volumes for any given period of time.,
ANP.21360, Automated Stainer
There is a schedule to change the solutions in automated stainers., NOTE: Solutions must be changed at intervals appropriate for the laboratory’s workload. Changing, filtering, or addition to solutions should be documented when performed.,
ANP.21382, Reagent Expiration Date
“All reagents are used within their indicated expiration dates., NOTE: The laboratory must assign an expiration date to any reagents that do not have a manufacturer-provided expiration date. The assigned expiration date should be based on known stability, frequency of use, storage conditions, and risk of contamination.
This checklist requirement applies to all reagents used in the laboratory (histochemical, immunohistochemical, and immunofluorescent reagents, and reagents used for molecular tests).
The acceptable performance of histochemical stains is determined by technical assessment on actual case material, use of suitable control sections, and as part of the pathologist’s diagnostic evaluation of a surgical pathology or autopsy pathology case.
An exception to the above is that some histochemical reagents used in the histology laboratory are not subject to outdating, so that assignment of expiration dates may have no meaning. The acceptable performance of such reagents should be confirmed at least annually by technical assessment, as described above. (If the manufacturer assigns an expiration date, it must be observed.)
For laboratories not subject to US regulations, expired reagents may be used only under the following circumstances: 1. The reagents are unique, rare or difficult to obtain; or 2. Delivery of new shipments of reagents is delayed through causes not under control of the laboratory. The laboratory must document verification of the performance of expired reagents in accordance with written laboratory policy. Laboratories subject to US regulations must not use expired reagents., “
ANP.21395, Special Stains/Studies
For special stains and studies using immunologic and FISH/ISH methods, results of controls are documented to be acceptable before reporting patient results., ,
ANP.21450, Special Stain Quality
All histochemical stains are of adequate quality, and daily controls are demonstrated on each day of use for the tissue components or organisms for which they were designed., NOTE: Positive tissue controls assess the performance of the special stain. Special stains are performed on sections of control tissue known to contain components specific to each special stain. Verification of tissue used as a positive control must be performed and documented before being used with clinical specimens.,
ANP.21850, QC - Immunofluorescence
For immunofluorescence microscopy, appropriate positive and negative controls are performed. , NOTE: Internal antigens serve as positive controls (e.g. IgA in tubular casts, IgG in protein droplets and C3 in blood vessels). When internal positive controls are absent, daily external positive controls are required. Non-reactive elements in the patient specimen may serve as a negative tissue control. A negative reagent control in which the patient tissue is processed in an identical manner to the test specimen, but with the primary antibody omitted, should be performed for each patient test specimen at the discretion of the laboratory director. ,
ANP.22300, Specimen Modification
If the laboratory performs immunohistochemical staining on specimens other than formalin-fixed, paraffin-embedded tissue, the written procedure describes appropriate modifications for other specimen types., NOTE: Such specimens include frozen sections, air-dried imprints, cytocentrifuge or other liquid-based preparations, decalcified tissue, and tissues fixed in alcohol blends or other fixatives.,
ANP.22500, Buffer pH
The pH of the buffers used in immunohistochemistry is routinely monitored., NOTE: pH must be tested when a new batch is prepared or received.,
ANP.22550, QC - Antibodies
“Positive tissue controls are used for each antibody., NOTE: Positive controls assess the performance of the primary antibody. They are performed on sections of tissue known to contain the target antigen, using the same epitope retrieval and immunostaining protocols as the patient tissue. Results of controls must be documented, either in internal laboratory records, or in the patient report. A statement in the report such as, “All controls show appropriate reactivity” is sufficient.
Ideally, the positive control tissue would be the same specimen type as the patient test specimen (e.g. small biopsy, large tissue section, cell block), and would be processed and fixed in the same manner (e.g. formalin-fixed, alcohol-fixed, decalcified) as the patient specimen. However, for most laboratories, it is not practical to maintain separate positive control samples to cover every possible combination of fixation, processing and specimen type. Thus, it is reasonable for a laboratory to maintain a bank of formalin-fixed tissue samples as its positive controls; these controls can be used for patient specimens that are of different type, or fixed/processed differently, providing that the laboratory can show that these patient specimens exhibit equivalent immunoreactivity. This can be accomplished by parallel testing a small panel of common markers to show that specimens of different type, or processed in a different way (e.g. alcohol-fixed cytology specimens, decalcified tissue) have equivalent immunoreactivity to routinely processed, formalin-fixed tissue.
A separate tissue section may be used as a positive control, but test sections often contain normal elements that express the antigen of interest (internal controls). Internal positive controls are acceptable for these antigens, but the laboratory manual must clearly state the manner in which internal positive controls are used.
A positive control section included on the same slide as the patient tissue is optimal practice because it helps identify failure to apply primary antibody or other critical reagent to the patient test slide; however, one separate positive control per staining run for each antibody in the run (batch control) may be sufficient provided that the control slide is closely scrutinized by a qualified reviewer.
Ideally, positive control tissues possess low levels of antigen expression, as is often seen in neoplasms. Exclusive use of normal tissues that have high levels of antigen expression may result in antibody titers of insufficient sensitivity, leading to false-negative results., “
ANP.22570, QC - Antibodies
“Appropriate negative controls are used., NOTE: Negative controls must assess the presence of nonspecific staining in patient tissue as well as the specificity of each antibody with the exception listed below. Results of controls must be documented, either in internal laboratory records, or in the patient report. A statement in the report such as, ““All controls show appropriate reactivity”” is sufficient.
For laboratories using older biotin-based detection systems, it is important to use a negative reagent control to assess nonspecific or aberrant staining in patient tissue related to the antigen retrieval conditions and/or detection system used. A separate section of patient tissue is processed using the same reagent and epitope retrieval protocol as the patient test slide, except that the primary antibody is omitted, and replaced by any one of the following:
- An unrelated antibody of the same isotype as the primary antibody (for monoclonal primary antibodies)
- An unrelated antibody from the same animal species as the primary antibody (for polyclonal primary antibodies)
- The negative control reagent included in the staining kit
- The diluent/buffer solution in which the primary antibody is diluted
In general, a separate negative reagent control should be run for each block of patient tissue being immunostained; however, for cases in which there is simultaneous staining of multiple blocks from the same specimen with the same antibody (e.g. cytokeratin staining of multiple axillary sentinel lymph nodes), performing a single negative control on one of the blocks may be sufficient provided that all such blocks are fixed and processed identically. This exception does not apply to stains on different types of tissues or those using different antigen retrieval protocols or antibody detection systems. The laboratory director must determine which cases will have only one negative reagent control, and this must be specified in the department’s procedure manual.
The negative reagent control would ideally control for each reagent protocol and antibody retrieval condition; however, large antibody panels often employ multiple antigen retrieval procedures. In such cases, a reasonable minimum control would be to perform the negative reagent control using the most aggressive retrieval procedure in the particular antibody panel. Aggressiveness of antigen retrieval (in decreasing order) is as follows: pressure cooker; enzyme digestion; boiling; microwave; steamer; water bath. High pH retrieval should be considered more aggressive than comparable retrieval in citrate buffer at pH 6.0.
Immunohistochemical tests using polymer-based detection systems (biotin-free) are sufficiently free of background reactivity to obviate the need for a negative reagent control and such controls may be omitted at the discretion of the laboratory director following appropriate validation.
It is also important to assess the specificity of each antibody by a negative tissue control, which must show no staining of tissues known to lack the antigen. The negative tissue control is processed using the same fixation, epitope retrieval and immunostaining protocols as the patient tissue. Unexpected positive staining of such tissues indicates that the test has lost specificity, perhaps because of improper antibody concentration or excessive antigen retrieval. Intrinsic properties of the test tissue may also be the cause of ““non-specific”” staining. For example, tissues with high endogenous biotin activity such as liver or renal tubules may simulate positive staining when using a detection method based on biotin labeling.
A negative tissue control must be processed for each antibody in a given run. Any of the following can serve as a negative tissue control:
- Multitissue blocks. These can provide simultaneous positive and negative tissue controls, and are considered “best practice” (see below).
- The positive control slide or patient test slides, if these slides contain tissue elements that should not react with the antibody.
- A separate negative tissue control slide.
The type of negative tissue control used (i.e. separate sections, internal controls or multitissue blocks) must be specified in the laboratory manual.
Multitissue blocks may be considered best practice and can have a major role in maintaining quality. When used as a combined positive and negative tissue control as mentioned above, they can serve as a permanent record documenting the sensitivity and specificity of every stain, particularly when mounted on the same slide as the patient tissue. When the components are chosen appropriately, multitissue blocks may be used for many different primary antibodies, decreasing the number of different control blocks needed by the laboratory. Multitissue blocks are also ideal for determining optimal titers of primary antibodies since they allow simultaneous evaluation of many different pieces of tissue. Finally, they are a useful and efficient means to screen new antibodies for sensitivity and specificity or new lots of antibody for consistency, which should be done before putting any antibody into diagnostic use., “
ANP.22615, Endogenous Biotin
“If the laboratory uses an avidin-biotin complex (ABC) detection system (or a related system such as streptavidin-biotin or neutravidin-biotin), there is a policy that addresses nonspecific false-positive staining from endogenous biotin., NOTE: Biotin is a coenzyme present in mitochondria, and cells that have abundant mitochondria such as hepatocytes, kidney tubules and many tumors (particularly carcinomas) are rich in endogenous biotin. Biotin-rich intranuclear inclusions are also seen in gestational endometrium and in some tumors that form morules. If steps are not included in the immunostaining method to block endogenous biotin before applying the ABC detection complex, nonspecific false-positive staining may occur, particularly when using heat-induced epitope retrieval (which markedly increases the detectability of endogenous biotin). This artifact is often exquisitely localized to tumor cells and may be easily misinterpreted as true immunoreactivity.
Blocking endogenous biotin involves incubating the slides with a solution of free avidin (which binds to endogenous biotin), followed by incubation with a biotin solution (which saturates any empty biotin-binding sites remaining on the avidin). Biotin-blocking steps should be performed immediately after epitope retrieval and before incubation with primary antibody., “
ANP.22660, Control Slide Review
“When batch controls are run, the laboratory director or designee reviews all control slides each day of patient testing., NOTE: Records of this daily review must be maintained and should clearly document that positive and negative controls for all antibodies stain appropriately. Batch control records must be retained for 2 years.
The batch control slides must be readily available to pathologists who are signing out cases. The location of the slides should be stated in the procedure manual., “
ANP.22750, Antibody Validation
“The laboratory has documented validation of new antibodies, including introduction of a new clone, prior to use in patient diagnosis., NOTE: The performance characteristics of each assay in the immunohistochemistry laboratory must be appropriately validated before being placed into clinical use. The initial goal is to establish the optimal antibody titration, detection system, and antigen retrieval protocol. Once optimized, a panel of tissues must be tested to determine the assay’s sensitivity and specificity. The scope of the validation is at the discretion of the laboratory director and will vary with the antibody. For a well-characterized antibody with a limited spectrum of antigenic targets, like chromogranin or prostate specific antigen, the validation can be limited. A panel of 10 positive and 10 negative neoplasms would be sufficient in this setting. For validation of predictive markers, consideration should be made for a larger validation set. For an antibody that is not well characterized and/or has a wide range of reported reactivity, a more extensive validation is necessary. The number of tissues tested should, in this circumstance, be large enough to determine whether the staining profile matches that previously described.
An exception to the above requirements is that studies may not be feasible for antigens that are only seen in rare tumors.
This checklist has additional validation requirements for HER2 and estrogen/progesterone receptor testing in breast carcinoma. Please refer to the subsection ““Predictive Markers,”” below., “
