Adequately fixed tissue is vital in the interpretation of histopathology.
All histology specimens should be placed in a suitable container as soon as possible, after being obtained. The container should be correctly labelled with patient’s name, unit number, address, including postcode, date of birth, Consultant, ward and GP (if known). The specimens should be placed in large enough containers to hold the specimen and approximately 10 times its volume of formalin.
Although the majority of specimens can be placed in formalin provided by the Histology Department, some biopsies will require an alternative or no fixative and the advice of the laboratory should be sought beforehand to ensure that a Pathologist is available to deal with the specimen on arrival. Such specimens include:
- Skin biopsies for Immunofluorescence
- Frozen sections
- Gout specimens
- Potential cases of special interest
All cases of exceptions to the general rule of using formal saline must be brought to Histopathology directly. On no account should they be left in the Pathology Laboratory reception, theatres or in the wards.
When biopsies are to be cultured, only part of the specimen should be placed in formalin, and part should be sent dry, in a sterile container, to the Microbiology Department with a separate request form. If this is not possible, contact the Histology Laboratory before sending the whole specimen, dry, to us with the Microbiology and Histology request forms. It is the responsibility of the doctors concerned with the case that this procedure is followed.
Specimens should not be cut into or partially opened, since such specimens distort badly on fixation, and are then very difficult to examine adequately.
If any case requires an urgent report on a paraffin section then the specimen should be brought directly to the Histology Department and the doctor concerned should contact the Pathologist and write ‘urgent’ on the request form.
- Electron microscopy and renal biopsies
The Clinician should contact the Consultant Histopathologist if this service is needed, otherwise specimens will be sent to Russell’s Hall Hospital, Dudley, only at the Pathologists discretion.
- Muscle or nerve biopsies
Prior arrangement is needed with the Histopathology Department at the Midland Centre for Neurosurgery at University Hospital. They need to be contacted by the Clinicians to make appropriate arrangements for the collection of the biopsy. Histology should also be notified as appropriate containers and reagents may need to be provided from this Centre. On no account should any specimen be left overnight in the ward or theatre refrigerators.
This type of specimen should NOT be sent to Histology. It is the responsibility of the Medical Officer in charge of the patient to make arrangements with the Regional Cytogenetics department at Heartlands Hospital as to their requirements and to pack the specimen appropriately. The requesting Medical Officer must also make arrangements for transport of the specimen either via the routine taxi service operated from Pathology reception or by booking a specific taxi request through the General Office. Tissue samples should be placed in normal saline and kept at 4°C if transport is delayed. Formalin must NOT be used at any time. Specimens will not be accepted by Cytogenetics between 4pm Friday and 9am Monday. For further details see Cytogenetics policy circulated to all Medical staff in the Obstetrics and Gynaecology department.
Rejection of specimens
No specimen will be accepted by the laboratory if:
- The specimen is unlabelled
- The request form is not completed
- Any specimen arrives without a request form
- Any request form arrives without a specimen
- Any specimen without matching details on the request form and specimen container
- Any infective specimens arriving in a broken container
- Any known infectious specimens arriving without appropriate hazard labelling and packaging
- Any combination of the above
All of the above specimens will be returned directly to their source for completion/verification of missing details and a near miss will be recorded on Safeguard. If the source is unknown, the specimen will remain in the Histology Department but no further action will be taken until appropriate details are completed by telephone call or personal visit from the Clinician/House Officer.
It is essential that all patient details are completed on the request form, or a pre-printed label should be attached. They should have at least three patient identifiers from:
- Date of birth
- NHS number
- Unit number
It is important that:
- The signature of the doctor making the request is legible so that he or she can be contacted for further details or for urgent communication.
- The details on the form and specimen are the same since discrepancies will cause delays.
- The ward or department given is the place to which the report will be sent, so if the pre-printed label is incorrect, it should be altered.
- The consultant’s name should also be given for all in-patient and outpatient request forms.
- The details of ‘nature of specimen and site’ should be completed on the histology form and as much clinical detail as possible must be given. In case of certain biopsies, for example, liver biopsy – details of LFT investigation results, drugs and any other relevant past history and investigations should be written on the form. In particular, we would like to know your provisional diagnosis, any other relevant diseases, previous operations, radiation, drug or hormone therapy and for female patients, date of LMP and normal menstrual cycle. We also need the slide reference numbers of all relevant previous biopsies or cytological specimens.
General practitioners making requests must ensure that the form includes:
- their name
- practice number
- telephone number
Handling of specimen
All pathology specimens should be treated as irreplaceable, therefore proper labelling and handling of specimens is essential. If we receive full information on the request forms, the reporting is quicker and time is not wasted in trying to contact the relevant doctor.
What happens to a specimen?
Histological specimens are usually placed into a fixative solution of 10% buffered formalin immediately after excision. Specimens are fixed for a minimum of 12 hours before being examined by a pathologist. The pathologist records the macroscopic appearance of the specimen, and for large specimens selects the pieces to be processed according to the tissue pathways provided by the Royal College of Pathologists. Small biopsies are processed completely. This tissue is then processed overnight into wax. The next working day, wax blocks are prepared from processed tissue with slides cut and stained for the pathologist to report. Wax blocks are then held for 30 years (and slides for 20 years) as per “The Retention and Storage of Pathological Records and Specimens” (Royal College of Pathologists, 2015) where they can be returned to if necessary.
Procedures requiring special handling
Tissue processing takes hours before sections are available. Please allow adequate time for processing and examination before enquiring on report progress.
Tissue from specimens are selected and processed overnight or over the weekend, in readiness for reporting the next working day. Delays in reports may be expected if extra fixing, special techniques or procedures or re-sampling is needed. For example,
- Large specimens like bowel or breast will need at least 24 – 48 hours fixing.
- Special staining techniques are needed for liver, lymph nodes, lungs, kidneys and tumour biopsies.
- Decalcification of bone or other calcified tissue can take several days.
In such cases, it may be possible to issue an interim report.
Report details are kept on computer files and the Data Protection Act requires those to be accurate.
If the request form has Consultant’s name clearly written and the urgent specimen reaches the laboratory by 4.00pm, then a report will be given (by the Consultant Histopathologist) the following morning to the requesting Consultant directly. Note that very few specimens are truly urgent.
For routine lists please give the laboratory 24-48 hours advance warning by telephoning patient details, nature of biopsy, surgeon, ward and time of operation.
- Phone details to extension 6477 or directly to the Consultant Histopathologists at extension 6235/7169/6484/7634.
- A provisional booking, with subsequent confirmation is preferable to inadequate notice.
- Inform the laboratory if requests are cancelled.
If the need for a frozen section arises unexpectedly, the request will be accommodated if possible.
The specimen should be sent dry and handed directly to a member of the technical or medical staff of the Histology Department. It should be accompanied by a correctly completed request form including the telephone number of the theatre to be contacted.
A rapid verbal report will be given on the frozen section and a typed report on a paraffin section of the tissue will normally follow within 48 hours.
On no account should known/suspected infected material with Hazard Group 3 or 4 pathogens, i.e., TB, Hepatitis B positive etc., material be sent for frozen section. (A 24-hour service is available for urgent cases).
Cases requiring Immunofluorescence
Skin biopsies requiring immunofluorescence should be sent in saline directly to the histopathology laboratory following excision. Please clearly label the specimen container and request form that immunofluorescence is required so that it may be dealt with promptly on arrival.
For routine specimens, it takes at least four days between the biopsy being taken and the pathologist having the slides to report. Resection specimens and/or complex specimens may, however, take longer. Diagnoses are usually made on sections stained by routine techniques, but not infrequently cases require more sophisticated and extensive studies. The department can offer a wide range of immunohistochemical methods.
The department monitors its turnaround times using the Key Performance Indicators as laid out by the Royal College of Pathologists (80% reported within 7 days and 90% within 10 days).
All histopathology specimens are kept for approximately 4 weeks following authorization. Blocks are kept for a minimum of 30 years should additional testing be required. Any additional tests must be arranged through direct contact with the reporting Consultant.
The choice of referral for a second clinical opinion is the decision of the reporting Consultant although many will be guided by regional agreement.
For cases requiring HER2 testing, blocks are sent to:
Birmingham Heartlands Hospital
Bordesley Green East
Birmingham B9 5SS
HER2 testing takes approximately 2 weeks.
For cases requiring Oncotype DX testing, blocks are sent to:
Genomic Health, INC,
301 Penobscot Drive,
Redwood City, CA 94063-4700
Oncotype DX testing takes approximately two weeks.
Reports are generated via the Secretariat and are dispatched to the sender source. If further copies are required please indicate on the request form.
Usually once a report is authorised in histopathology it can be looked at on Fusion and/or a paper copy will be sent out to the clinician for insertion into the patient’s notes. It is the responsibility of the user to perform this action.
Verbal reports shall only be given if the report is authorised and to the requesting clinician. Unauthorised reports shall not be given by laboratory staff and the case should be discussed with the reporting pathologist.
The Royal College of Pathology supplies minimum datasets which are used in the standardised reporting and staging of cancer to the TNM system.