Hematopathology Resident / Fellow Manual

Transcription

DIVISION OF HEMATOPATHOLOGY
HEMATOPATHOLOGY HANDBOOK
FOR
RESIDENTS AND FELLOWS
August 2016
STEVEN H. SWERDLOW, MD
DIRECTOR, DIVISION OF HEMATOPATHOLOGY
GRANT BULLOCK, MD
LYDIA CONTIS, MD
MIROSLAV DJOKIC, MD
SARAH GIBSON, MD
NIDHI AGGARWAL, MD
SARA MONAGHAN, MD
The Division acknowledges the help of Ms. J. Klimkowicz in putting this
handbook together and keeping it up to date.
TABLE OF CONTENTS
(Ctrl +click on blue hyperlink to go to section)
IMPORTANT TELEPHONE NUMBERS LIST
GENERAL OUTLINE FOR HEMATOPATHOLOGY ROTATION
5
RESIDENT EVALUATION METHODS AND DOCUMENTATION
7
11
18
CONFERENCE SCHEDULE AND RESPONSIBILITIES
40
PEDIATRIC AND GENERAL HEMATOLOGY LABORATORY EXPERIENCE
GENERAL/SPECIAL HEMATOLOGY LABORATORY EXPERIENCE CHECKLIST
PEDIATRIC HEMATOPATHOLOGY CHECKLIST
UPMC PRESBYTERIAN SHADYSIDE AUTOMATED TESTING LABORATORY
PATHOLOGIST REVIEW FORM/CHP ATL PATHOLOGIST REVIEW FORM
26
29
41
49
CLINICAL EXPERIENCE IN HEMATOLOGY
CLINICAL HEMATOLOGY/PERFORMANCE OF BONE MARROW EXPERIENCE
51
52
PERFORMANCE OF BONE MARROW ASPIRATIONS & BIOPSIES
53
55
HEMATOPATHOLOGY PROGRESSIVE GOALS AND OBJECTIVES
HEMATOPATHOLOGY ROTATION PERFORMANCE OF MARROW BIOPSIES AND ASPIRATES FORM
FLOW CYTOMETRY LABORATORY EXPERIENCE
FLOW CYTOMETRY ROTATION CHECKLIST
FLOW CYTOMETRY PANELS, AVAILABLE ANTIBODIES, GUIDELINES,
TEST SPECIFICATIONS FOR CLINICAL FLOW CYTOMETRY LABORATORY
ICD9 CODES FOR FLOW
ADULT BONE MARROW EXPERIENCE
GENERAL TRAINEE RESPONSIBILITIES DURING BONE MARROW ROTATION
SPECIFIC GUIDELINES FOR RESIDENTS AND FELLOWS ON BONE MARROW SERVICE
BONE MARROW ADEQUACY CRITERIA
POLICY FOR REVIEW OF BONE MARROW ASPIRATES AND BIOPSIES
BONE MARROW CHECKLIST
89
91
60
71
73
106
108
110
111
112
113
FORMS AND TEMPLATES FOR BONE MARROW SERVICE
RECOMMENDATIONS FOR CONSISTENT TERMINOLOGY
AJCC PROTOCOL FOR EXAMINATIOM OF SPECIMINS FROM PATIENTS WITH
HEMATOPOIETIC NEOPLASMS INVOLVING THE BONE MARROW
123
135
BONE MARROW LABORATORY TEST SPECIFICATIONS
SUMMARY OF TEST SPECIFICATION FOR ANCILLARY LABORATORIES
150
151
BONE_MARROW_AFTER_HOURS_PROCEDURES
154
138
TABLE OF CONTENTS (cont.)
LYMPH NODE EXPERIENCE
SURGICAL PATHOLOGY MANUAL: LYMPH NODE PROTOCOL
SURGICAL PATHOLOGY MANUAL: SPLEEN PROTOCOL
LYMPH NODE GROSS DICTATION-TEMPLATE
POLICY FOR SOLID TISSUE SPECIMENS
INSTRUCTIONS FOR FRESH TISSUE BIOPSIES RECEIVED FROM OUTSIDE INSTITUTIONS
FRESH CASE LYMPH NODES AND OTHER SOLID TISSUES SENT FOR FLOW CYTOMETRY
HELPFUL HINTS FOR HANDLING CONSULT BLOCKS &
SENDING OUTSIDE BLOCKS TO HISTOLOGY
RULES FOR HISTOLOGY
GENERAL FORMATTING REQUIREMENTS
LYMPH NODE/SOLID TISSUE ORGANIZATION OF SIGNOUT MATERIAL
HEMATOPATHOLOGY CASE WORKSHEET
LYMPH NODE ROTATION CHECKLIST
AJCC PROTOCOL FOR EXAMINTION OF SPECIMENS FROM PATIENT WITH
NON-HODGKIN LYMPHOMA/LYMPHOID NEOPLASMS
AJCC PROTOCOL FOR THE EXAMINATION OF SPECIMENS FROM PATIENTS WITH
HODGKIN LYMPHOMA
IMMUNOHISTOCHEMISTRY
158
160
170
171
172
173
174
175
176
179
185
187
192
201
217
IMMUNOSTAINS/IN-SITU HYBRIDIZATION LABORATORY AND ORDERING INFORMATION
STAINS FREQUENTLY USED IN HEMATOPATHOLOGY: CODES AND REACTIVITIES
COMPLETE IMMUNOHISTOCHEMICAL STAIN ABBREVIATIONS/CODES
IN-SITU HYBRIDIZATION PROBES AVAILABLE
222
223
225
228
236
IHC/ISH REPORTING TEMPLATES
237
MOLECULAR DIAGNOSTIC AND CYTOGENETICS
FLUORESCENCE IN SITU HYBRIDIZATION – PITTSBURGH
CYTOGENETICS LABORATORY
240
242
COPATH AND DICTATION POINTERS
DICTATING & PROOFING TISSUE REPORTS
250
253
SYNOPTICS
256
WEB-BASED RESOURCES
273
Contents of Supplementary Information
See the following hard copy supplementary information:
1. Schedules
 Master Hematopathology
 Flow Cytometry Conference
 Journal Club
 Patient Safety and Risk Management Hematopathology Conference
 Pediatric Tumor Board
 Conference Schedule
 Hematopathology Core Resident Rotation
2. Forms to turn into Hematopathology Coordinator Jessica Klimkowicz:
 Performance of Marrow Biopsies and Aspirates Form (2)
 Laboratory Hematology Check List
 Flow Cytometry Experience Checklist
 Lymph Node Experience Checklist
 Pediatric Hematology Experience Checklist
 Bone Marrow Experience Checklist
3. Material for Laboratory Hematology
 Red Cell Morphology Classification
 Complete Blood Count Evaluation
 Continuing Education in Clinical Chemistry and Hematology Conference Responsibilities
4. Miscellaneous
 Progressive Goals and Objectives
 Faculty/Fellow Phone List
 Sure-handed Sampling/Easing the Trauma of Bone Marrow Collection
 Resident Evaluation Methods
 Dictating and Proofing Tissue Reports
 CD
 Hematopathology Handbook for Residents and Fellows
 Automated Hematology Instrumentation
 Grossing Fresh Lymph Nodes (PowerPoint Presentation)
 Neutrophil Oxidative Burst Assay (NOBA)
 Hemoglobinopathies (PowerPoint Presentation)
 Chromatin interpretation guide for hemoglobinopathies (PDF)
HEMATOPATHOLOGY
FACULTY
Long Range
Pager
In House
Pager
Grant Bullock, MD, PhD
Lydia Contis, MD
Miroslav Djokic, MD
Sarah Gibson, MD
Nidhi Aggarwal, MD
Steven H. Swerdlow, MD
412-958-6254
412-433-9364
412-958-5267
412-958-5723
412-958-6063
412-392-7445
Long Range
Pager
412-958-2236
412-270-0352
412-958-2246
10356
2296
14609
13155
4467
2826
In House
Pager
4678
8507
4684
FELLOWS
Casey Gooden, MD
Rebeca Leeman-Neill, MD
Erika Moore, MD
Lymph Node Assistant
Lisa Fitchwell
Michelle Asturi
Cytogenetics/Hours of
FISH Lab
Dr. Urvashi Surti
Dr. Susanne Gollin
Maureen Sherer
Technologist Pager
Molecular Diagnostics
Molec Fellows
Molec Sign-Out
Dr. Zoltan Oltvai
Dr. Tim Oury
Dr. Marie DeFrances
Office #
Coordinator/Secretary
412-624-7523
412-647-0264
412-692-2128
412-647-4162
412-864-6185
412-647-5191
412-647-5191
412-647-5191
412-647-5191
412-647-5191
412-647-5191
Jessica Klimkowicz 412-578-9423
Office #
Coordinator/Secretary
412-647-1877
412-647-0435
412-578-9239
N/A
N/A
N/A
412-958-7432
10768
412-647-5869
N/A
----------------------------412-647-0263
N/A
412-641-6688 (Weekend pager: 412-917-9458-messages will be checked until 3PM)
412-641-3434
412-917-9333
--------------412-641-4267
----------------------------412-624-5390
Noel Eisel Harrie
----------------------------412-641-6685
--------------412-917-9458 (Sat./Sun./Holidays until 3:00pm)
412-864-6150 (CLB)
412-864-6155
412-864-6153
----------------------------412-864-6150
----------------------------412-648-9659
----------------------------412-648-8346
Miscellaneous
Phone Number
Location
Supervisor
Bone Marrow Lab
Bone Marrow Audix
Bone Marrow Sign Out
412-647-0263
412-802-3273
412-647-5881
G325.1
Celina Fortunato
“Non-Stat” Requests
G315
---------------
Lead Technologist
Celina Fortunato 412-802-3272
-----------------Mike
Swiatkowski
7-3:30
Routine
histology and
special stain
issues
CLB
Marina Rahman
412-864-6123
Tisha
Harrison
5am-1:30pm
immunopero
xidase
issues
412-647-5262
G323
---------------
------------------
Consult Accessioning
412-864-6175
CLB 9032
Celina Fortunato
Celina Fortunato 412-802-3272
Automated Testing Lab
412-647-1022/
heme bench
76199
5 Fl CLB
Katie Mulvey
412-647-6517
Mary Vernetti/Chris Morain 6414662/624-2462 (Heme)
412-623-1595
WG02.18
412-864-6173
412-864-6182
CLB 9032
SHY Hematology Lab
412-623-6011
Shadyside Fl
G-Main
Microlab Adult
412-647-3727
412-692-5325
412-692-5665
PUH A802
CHP
Lawrenceville
Histology
412-647-7660
IPEX
Lymph Node Sign Out /
Resource Room
412-647-7663
SHY Automated Testing
Lab
Flow Laboratory
Flow Laboratory Extras
CHP ATL
th
Darla Lower 6231595
Pager
412-565-9553
Ruth Bates 412-864-6180
Darla Lower
Tammy Garrett
412-623-1595
Frances Hardic 412-647-7711
Lorraine Heffelfinger 412-692-7611 /
Marianne Riazzi 412-692-9836
Mary Mullen
3-11:30
Evening
routine &
immunopero
xidase issues
GENERAL OUTLINE FOR
HEMATOPATHOLOGY
ROTATION
General Outline for Hematopathology Rotations
Core Rotation for Residents
The approximately three-month core hematopathology rotation offers the resident an
introduction to the many facets of this complex field. It is hoped that the resident will begin to
become familiar with the multiparameter approach to adult and pediatric diagnostic
hematopathology (bone marrows and lymph nodes) as well as with techniques used in general
and special hematology laboratories, and the flow cytometry laboratory. Finally he/she will learn
about major neoplastic and non-neoplastic disease entities that involve the hematopoietic and
lymphoid cell lineage. If interested, more advanced subsequent rotations can be arranged in
one or more areas within the division. It is fully recognized that the resident cannot fully achieve
all of the objectives listed within a period of three months. The different sections within the
rotation are usually, but not always carried out in the order they are listed here. The educational
resources noted below are located in rooms G304 (conference room), G315 (bone marrow signout room) and G323 (lymph node sign-out room) depending on their subject matter.
Cytogenetics is a separate rotation, but residents will learn how cytogenetic data is used in
diagnostic hematopathology.
Syllabus Statement Concerning Students with Disabilities
If you have a disability for which you are or may be requesting an accommodation, you are
encouraged to contact Dr. Swerdlow, Dr. Gibson or their designate prior to your rotation so
reasonable accommodations can be made.
Elective Rotations
This handbook also serves as a resource for upper level resident rotations that can concentrate
on any of the areas in hematopathology.
Fellow Rotations
This handbook also is a major supplement to the fellow handbook as they also follow the basic
procedures outlined here for the rotations that overlap with hematopathology resident rotations.
The expectations are greater for the fellows in terms of their knowledge base, clinical skills and
ability to utilize multiple resources to make specific diagnoses. Accordingly they are given
enhanced responsibilities.
Hematopathology Twelve Week Core Resident Rotation
Week
Activities
1
Orientation with Dr. Gibson or designee.
Lymph Node
2
Lymph Node
3
Lymph Node
4
Lymph Node
5
Peds/Wet & ASCP image set/BM tech review
6
Peds/Wet
7
Peds/Wet
8
Days 1-3 AM Shadyside (Go to Hemepath Conference Wed AM)
Days 3 PM – 4,5 Flow Rotation
9
Adult Bone Marrow
10
Adult Bone Marrow
11
Adult Bone Marrow
12
Adult Bone Marrow
1. Lymph Node Pathology (~ 4 weeks)
1. Lymph Node Sign Out.
2. Review of educational materials (See Lymph Node Experience section).
Goals and Objectives:
1.
Learn the use of multiparameter approach to diagnostic lymph node pathology as
well as extranodal hematopoietic/lymphoid proliferations.
2.
Learn normal nodal histology and basic reactive patterns.
3.
Begin to develop a basic understanding of Hodgkin’s Lymphoma, the nonHodgkin’s lymphomas and reactive lymphoid hyperplasias. Be able to diagnose
straightforward cases of the above.
4.
Complete lymph node rotation checklist.
2. Pediatric Hematopathology and General/Special Hematology Laboratory
Experience (~ 3 weeks)
Trainees should report to the pathologist signing out CHP bone marrows and to Dr. Contis or
her designate after their general rotation orientation or at the start of the rotation. Trainees
should also meet with Dr. Contis or her designate at the midpoint to review progress on the
rotation and at the completion of the rotation. Inform the pathologist covering the general
hematology laboratory as well. The trainee will give one ~15 minute presentation near the end
of this section of the rotation. This period should also be used to review the ASCP image series
on normal and abnormal peripheral blood and bone marrow examinations.
Pediatric Hematopathology Experience
1.
Introduction to basic bone marrow/peripheral blood interpretation.
2.
Pediatric Bone Marrow Sign out.
3.
Observation of pediatric marrow examination procedures.
4.
Review pediatric material from Automated Testing Laboratory and Flow
Cytometry Laboratory.
5.
Review of educational materials (See Pediatric Hematopathology Experience
section).
1.
Develop basic skills in the interpretation of peripheral blood, bone marrow and
fluid evaluations.
2.
Develop familiarity with issues unique to pediatric hematopathology, both
pathologic and clinical.
3.
Develop basic skills in hematopathologic ancillary studies.
4.
Complete pediatric hematopathology checklist.
5.
Complete pediatric bone marrow observation form.
General/Special Hematology Laboratory Experience
1.
Automated Testing Laboratory Experience.
2.
Special Hematology Testing Experience.
3.
Review of educational materials.
4.
Presentation to technologists.
1.
Learn the major aspects of non-neoplastic hematology including red blood cell,
white blood and platelet abnormalities and the way in which the laboratory helps
in the diagnosis and follow-up of hematologic/lymphoid neoplasms.
2.
Understand the principles of urinalysis and how it is used to help diagnose renal
and systemic disorders.
3.
Understand automated hematology and urinalysis instrumentation.
4.
Develop understanding of how a large complex patient-oriented clinical
laboratory facility is managed. This includes an appreciation of the scope of the
testing, testing methodology and documentation of test accuracy.
5.
Learn the scope and practices of “Special Hematology” testing and how it is
utilized to diagnose hematologic disorders.
6.
Complete general/special hematology experience checklist.
3. Clinical experience in Hematology/Performance of Bone Marrows (with
Hematology/Oncology Division) (2 ½ days)
Attend varied clinics at UPMC-Shadyside/Hillman Cancer Center to observe the clinical
aspects of hematology and understand the needs of both patients and their physicians.
Trainees are expected to learn how to perform bone marrow aspirations and biopsies.
They should aim to observe and then perform several marrows. Because it is expected
that during this rotation residents will perform no more that 5 marrows, they should
complete this requirement on their later VA rotation (Dr. M. Melhem). Be sure to
complete the BM performance form that requires signatures of the person who
supervised your marrow examinations and the pathologist who reviewed the slides.
NOTE: Appropriate dress is required to see patients (white coat, men need to wear a
tie).
1.
Gain experience performing bone marrow aspirates and biopsies.
2.
Learn more about clinical implications of hematopathology diagnoses and impact
on patients as a person.
3.
Provide opportunities to perform bone marrow examinations.
4.
Learn what type of consultations clinicians expect from hematopathologists.
5.
Complete the bone marrow performance form.
4. Flow Cytometry Laboratory Experience (2½ days)
Understanding of flow cytometric immunophenotypic techniques and interpretation of the
resultant data is an integral part of all the bone marrow and lymph node rotations. In
addition, however there is a brief concentrated exposure to the flow cytometry laboratory
including the technical aspects of flow cytometry and the basic operation of a flow
cytometry laboratory. The resident should report to Ruth Bates or their designate.
1.
Understand sample preparation; basic flow cytometry, quality control, gating on
specific cell populations, and determination of positive versus negative staining
and methods of data presentation.
2.
Know indications for testing, taking into account cost effective medicine
3.
Complete flow cytometry checklist.
5. Adult Bone Marrow Experience (~ 4 weeks)
A. Limited Sessions with Adult Bone Marrow Technologist.
B. Responsibility for review of selected cases prior to sign-out.
C. Participation in sign-out with staff.
D. Review of educational materials (See Adult Bone Marrow Experience section).
1.
Learn normal and abnormal blood cell morphology.
2.
Learn basic approach to bone marrow aspirate, biopsy and particle preparation
interpretation.
3.
Begin to become familiar with the use of ancillary studies used in the diagnosis of
bone marrow examinations.
4.
Begin to develop a basic understanding of the more common neoplastic and nonneoplastic disorders which involve the marrow: acute and chronic leukemias,
myelodysplasias, myeloproliferative disorders, anemias, thrombocytopenias,
leukopenias, thrombocytosis, leukocytosis, infections (including HIV), and
metastatic neoplasms. Be able to diagnose straightforward cases of the above.
5.
Complete bone marrow rotation checklist.
Hematopathology Progressive Goals and Objectives
Competency
Core Rotation - 1st to Core Rotation – 1st Elective Rotation - 3rd and
3rd Year Resident
to 3rd year Resident 4th year Resident
Beginning of
Later in Rotation
Rotation
Professionalism Reliable, punctual,
Fellow
Second Year
Post Fellowship
Experience
In addition to elements
In addition to elements In addition to prior
already noted, can help advise noted for residents,
accomplishments,
more junior trainees and serve functions so that others interacts with other
as a more senior role model. perceive fellow more like faculty and clinicians like
a junior faculty member. a more confident junior
Create a professional
faculty member, able to
CV. Conduct a
construct and maintain
successful job search if professional c.v. and
not continuing as a
biosketch
fellow.
Preview marrow
Preview marrow
Write and dictate reports for Independently work-up Able to provide a
aspirate smears with aspirate smears
most routine cases.
and complete the
complete diagnostic
direct faculty guidance. semi-independently,
majority of cases.
report to attending
Review cases, record directly interact with
faculty with minimal
observations,
technologists.
required changes.
formulate differential Review cases, record
diagnosis.
observations,
formulate more
complete differential
diagnosis
appropriate
appearance, ethical
behavior, sensitive to
issues of diversity,
HIPAA compliant
Patient Care
Fellow
First Year
Same as near
beginning of rotation
but projects more
confidence and
handles difficult
situations with
greater ease.
Formulate list of
Formulate more
Independently order ancillary
immunohistochemical educated list of
studies in a resource
stains, cytochemical immunohistochemical conscious way on most
stains, flow antibody stains, cytochemical routine cases.
combinations to
stains, flow antibody
resolve differential
combinations to
diagnosis. Review data resolve differential
from ancillary studies diagnosis. Review
Independently order
ancillary studies in a
resource conscious way
on routine and most
complex cases.
Independently order
ancillary studies in a
resource conscious way
on virtually all cases.
Competency
3rd Year Resident
Beginning of
Later in Rotation
Rotation
and record
interpretation.
data from ancillary
studies and record
more complete
interpretation.
Gross specimens for
lymphoma work-up
with directed
supervision.
Gross specimens for
lymphoma work-up
with supervision as
needed (after
consulting fellow or
appropriate faculty).
Gross specimens for
lymphoma work-up with
limited supervision and select
ancillary testing independently
for most routine cases.
Fellow
First Year
Fellow
Second Year
Post Fellowship
Experience
Gross specimens for
Able to gross and triage
lymphoma work-up with specimens
very limited supervision independently and to
and select ancillary
supervise and instruct
testing independently for more junior trainees.
the majority of cases.
Be able to help instruct
junior trainees.
With explicit directions, With less explicit
Function as a critical
Independently function Able to supervise more
interact with clinicians directions, interact
consultant to clinical
as a critical consultant to junior trainee’s
and support staff.
with clinicians and
physicians and support staff clinical physicians.
presentations and
support staff.
with some supervision.
provide guidance for
preparation.
Be able to provide
Be able to provide
Provide
Provide
Provide
basic review of
basic review of
consultative/laboratory report consultative/laboratory consultative/laboratory
peripheral blood and peripheral blood,
for general and special
report for general and report for general and
interpret most common fluids and urines and hematology tests, peripheral special hematology
special hematology
hematology tests.
interpret most
blood and fluid reviews
tests, peripheral blood tests, peripheral blood
standard hematology working with faculty on more and fluid reviews on
and fluid reviews in all
tests.
complex cases and with
simple and complex
cases with only limited
limited assistance on less
cases relatively
supervision.
complex cases.
independently but with
final approval by faculty
member.
Competency
Medical
Knowledge
3rd Year Resident
Beginning of
Later in Rotation
Rotation
Fellow
First Year
Observe how others
handle laboratory
management issues.
Get involved in
laboratory management
issues with more limited
supervision.
Participate with
Get directly involved in
faculty/senior
laboratory management
technical staff in
issues with supervision.
laboratory
management issues.
Present at interPresent at interPresent at inter-departmental
departmental CPC
departmental CPC
CPC conferences with limited
conferences with
conferences with less supervision.
extensive supervision. direct supervision.
Knowledge of
Know criteria for
Know criteria for some of the
morphology and
major neoplastic and less common
immunophenotype of non-neoplastic
hematopathologic entities in
normal lymph node,
hematopathologic
addition to those for major
spleen, bone marrow entities.
entities.
and peripheral blood. Know specific
Knowledge of
approach used to
multiparameter
diagnose major
approach to diagnosis neoplastic and nonof hematologic
neoplastic
disorders.
hematologic entities.
Fellow
Second Year
Post Fellowship
Experience
Participate in continuing
education of
technologists and
support staff to improve
patient care.
Independently present at Presents cases at
inter-departmental CPC clinical CPC
conferences.
conferences without
supervision.
Have an extensive
Further increase
knowledge of broad
hematopathology
range of neoplastic and knowledge base in terms
non-neoplastic
of rare entities and
hematopoietic/lymphoid variations within more
disorders and other
common entities. Learn
disorders that involve or more about the type of
affect the
cases that lack a
hematolymphoid system definitive diagnosis.
including the pathologic Demonstrates ability to
and clinical aspects of apply and discuss
these disorders.
knowledge learned from
instructional workshops
or conferences attended.
Recognize some of the Recognize additional Recognize most common and Recognizes broad range Demonstrates an
more common
common neoplastic some uncommon neoplastic of hematologic disorders appreciation of the
neoplastic and nonand non-neoplastic and non-neoplastic disorders and recognizes when a limitation(s) of current
neoplastic disorders. disorders and know of the hematolymphoid system definitive diagnosis
diagnostic
Know basic
ways in which
and know the
cannot be rendered or schemes/classification
immunophenotypic/
specific entities are immunophenotypic,
where consultative help systems (i.e. shows
genotypic/cytogenetic further subdivided. In cytogenetic and genotypic
may be required.
recognition for “gray
features where
addition to basic
characteristics.
zones” in diagnosis).
Competency
3rd Year Resident
Beginning of
Later in Rotation
Rotation
Fellow
First Year
appropriate.
Complete “extended
version” of all rotation
checklists.
ancillary data
features, know
pathophysiologic
features of major
entities. Complete
greater than 80% of
resident version of
rotation checklist.
Completes more of
appropriate checklists and
sees more entities previously
encountered through reading.
Complete greater than 90% of
resident version of rotation
checklist.
Know basic
Know basic
Know full armamentarium of
components of
components of
hematology testing, the
complete blood count complete blood count purpose of each test and how
and how they are
and other major
to interpret combinations of
obtained.
hematology tests and tests. Know new
how they are
developments in hematology
obtained including
instrumentation.
major pitfalls. Also
know basic principles
of fluid and urinalysis
interpretations.
Know disease
entities where
diagnosis is based in
large part on
hematology
laboratory testing.
Practice-based Become familiar with Search literature for Critically analyze literature
Learning
basic hematopathology information pertaining and other sources of new
educational resources. to cases and apply it information pertaining to
to diagnostic
cases.
appraisals at sign-out
In addition to resident
accomplishments, know
details of more esoteric
testing and what is on
the horizon for
laboratory hematology.
Know how to evaluate
new instrumentation.
Fellow
Second Year
Post Fellowship
Experience
Be able to teach others
about laboratory
hematology including
factual and interpretive
elements.
Have a broad
Master all skill
knowledge of the
expectations listed for
hematopathology
more junior residents
resources and literature and first year fellow.
and be able to apply this Use information
Competency
3rd Year Resident
Beginning of
Later in Rotation
Rotation
Fellow
First Year
Fellow
Second Year
Post Fellowship
Experience
and at conferences.
information to daily
independently to alter
practice including
personal practice.
dealing with unusual
cases
Start to develop
Knows the differential Able to construct more
Demonstrates ability to Demonstrates ability to
diagnostic differentials diagnoses to
extensive differentials and
use textbooks and
apply knowledge from
for some of the more consider for more
apply knowledge by deciding medical literature to
medical literature in
common neoplastic
commonly
what stains and ancillary
construct a differential constructing a diagnostic
and non-neoplastic
encountered
testing would aid in
diagnosis for most cases differential or choosing
disorders with
neoplastic and non- distinguishing amongst the
and decide what
an appropriate work-up
significant faculty input. neoplastic disorders. diagnostic possibilities being ancillary testing would strategy of stains,
considered.
be useful.
ancillary testing, etc.
Construct reports
based on others’
examples.
Improve reports
based on comments Produce reports based on
received back from comments received back from
the faculty.
the faculty who require few, if
any, changes.
Develop complete
Have established style
reports that reflect
for producing final
divisional style based on reports that reflects an
continued input from
integration of input from
faculty, integrating the varied faculty and
best suggestions from integrate additional
varied individuals.
suggestions received on
reports.
Independently use other
colleagues and faculty Demonstrates ability to
as learning resources. utilize other professional
colleagues as learning
resource(s).
Interpersonal/ Present with clarity in Present with clarity in
Communication conference settings
conference settings
Skills
with significant faculty with minimal faculty
Competency
3rd Year Resident
Beginning of
Later in Rotation
Rotation
guidance.
assistance.
Works well with
technologists and
support staff and
learns from them.
Greater interaction Can serve as a greater
with technologists,
resource for technical staff.
including
demonstrating an
ability to teach them.
Fellow
First Year
Demonstrates the ability
to present information to
technologists and junior
residents at levels
appropriate for the
audience.
Fellow
Second Year
Post Fellowship
Experience
Able to educate
technologists and
residents with ease in
more impromptu settings
as appropriate.
Proactively seeks
opportunities to educate
others.
Contact clinicians to
Able to convey
Discuss preliminary reports
Able to convey complex Able to function as a
obtain clinical and
straightforward
and diagnoses with clinicians information to clinicians junior faculty in terms of
other information.
information to
with ease. Able to convey
and consulting
providing consultative
clinicians.
more complex information to pathologists and can
information to staff
clinicians and consulting
answer questions about pathologists at UPMC
pathologists.
diagnoses or work-up. and elsewhere as well
Also able to discuss
as with clinicians.
clinical implications of
diagnoses in depth.
System based Know and utilize basic Know and more fully Learn about outside regulatory Learn about the
Demonstrates
Practice
aspects of resources utilize resources
agencies/organizations.
administrative and
understanding of more
available in health
available in health
Develop an appreciation of
technical functions of
complex personnel
system i.e. computer system.
basic healthcare/pathology
running the Division of management issues.
systems (CoPath,
related financial issues.
Hematopathology.
Understands the various
MARS), laboratories
Perform a mock CAP
Perform a mock CAP
components of a
(hematology,
inspection, if possible.
inspection, if possible. diagnostic
molecular diagnostics,
hematopathology
cytogenetics,
service and the
histology), grossing,
interaction with other
bone marrow
related, but separate
laboratories.
services, such as
Competency
3rd Year Resident
Beginning of
Later in Rotation
Rotation
Fellow
First Year
Fellow
Second Year
Post Fellowship
Experience
cytogenetics and
molecular laboratories).
Has basic understanding
of hospital budgetary
issues that may be
specific to
hematopathology or
pathology in general.
RESIDENT EVALUATION METHODS AND DOCUMENTATION
in the Division of Hematopathology
A) Hematopathology Test for Residents:
1.
2.
3.
Subject Material:
 Images, glass slides and/or laboratory data from areas of rotation that have been completed:
o Bone marrow
o Laboratory hematology
o Lymph node
Evaluation Method:
 Review information provided
 Examine glass slides and/or images with other laboratory/clinical data provided
 Select best diagnosis from list of choices
Dates administered – Approximately 1½ weeks prior to completion of core hematopathology rotation
blocks.
B) Completion of Checklists according to rotation service (Bone Marrow, Lymph Node, Pediatric
Hematopathology, Laboratory Hematology)
C) Department of Pathology Resident Evaluation Forms (covering multiple competencies)
D) Documentation of Observation and Performance of Bone Marrow Aspirates and Biopsies by Completion of
Bone Marrow Performance Form
E) Documentation of Conference Attendance at Journal Club, Interesting Case Conference, Wednesday
morning Hematopathology Conference
F) Faculty and staff observation of performance in conferences and sign-out and general observations
regarding interpersonal relationships, communication skills and professionalism, including utilization of
departmental and extra-departmental resources
G) Personal Meeting with Director or designate at end of core rotation segments
The Pathology Milestone Project
A Joint Initiative of
The Accreditation Council for Graduate Medical Education
and
The American Board of Pathology
September 2013
Please see the website (https://www.acgme.org/acgmeweb/Portals/0/PDFs/Milestones/PathologyMilestones.pdf) for
most current version of Pathology Milestones
The Pathology Milestone Project
The Milestones are designed only for use in evaluation of resident physicians in the context of their
participation in ACGME-accredited residency or fellowship programs. The Milestones provide a framework
for the assessment of the development of the resident physician in key dimensions of the elements of
physician competency in a specialty or subspecialty. They neither represent the entirety of the dimensions
of the six domains of physician competency, nor are they designed to be relevant in any other context.
i
Pathology Milestone Group
Chair: Wesley Y. Naritoku, MD, PhD
Vice Chair: C. Bruce Alexander, MD
Betsy D. Bennett, MD, PhD
Mark Brissette, MD Margaret
M. Grimes, MD, MEd Robert D.
Hoffman, MD, PhD Jennifer
Leigh Hunt, MD
Julia C. Iezzoni, MD
Rebecca Johnson, MD
Resident Member: Jessica Kozel, MD
Resident Member: Ricardo M. Mendoza, MD
Steven P. Nestler, PhD
Miriam D. Post, MD
Suzanne Z. Powell, MD
Gary W. Procop, MD, MS
Stephen Black-Schaffer, MD
Jacob J. Steinberg, MD
Linda Thorsen, MA
ii
Milestone Reporting
This document presents milestones designed for programs to use in semi-annual review of resident performance and
reporting to ACGME. Milestones are knowledge, skills, attitudes, and other attributes for each of the ACGME competencies
organized in a developmental framework from less to more advanced. They are descriptors and targets for resident
performance as a resident moves from entry into residency through graduation. In the initial years of implementation, the
Review Committee will examine milestone performance data for each program’s residents as one element in the Next
Accreditation System (NAS) to determine whether residents overall are progressing.
For each reporting period, review and reporting will involve selecting the level of milestones that best describes each
resident’s current performance level in relation to milestones. Milestones are arranged into numbered levels. Selection of a
level implies that the resident substantially demonstrates the milestones in that level, as well as those in lower levels. (See
Reporting Form diagram on page v below.) A general interpretation of each level for pathology is below:
Level 1: The resident is a graduating medical student/experiencing first day of residency.
Level 2: The resident is advancing and demonstrating additional milestones.
Level 3: The resident continues to advance and demonstrate additional milestones; the resident consistently demonstrates
the majority of milestones targeted for residency.
Level 4: The resident has advanced so that he or she now substantially demonstrates the milestones targeted for residency.
This level is designed as the graduation target.
Level 5: The resident has advanced beyond performance targets set for residency and is demonstrating “aspirational” goals
which might describe the performance of someone who has been in practice for several years. It is expected that
only a few exceptional residents will reach this level.
3
Additional Notes
Level 4 is designed as the graduation target but does not represent a graduation requirement. Making decisions about
readiness for graduation is the purview of the residency program director. (See the following NAS FAQ for educational
milestones on the ACGME’s NAS microsite for further discussion of this issue: “Can a resident graduate if he or she does not
reach every milestone?”) Study of milestone performance data will be required before the ACGME and its partners will be
able to determine whether Level 4 milestones and milestones in lower levels are in the appropriate level within the
developmental framework, and whether milestone data are of sufficient quality to be used for high stakes decisions.
Some milestone descriptions include statements about performing independently. These activities must follow the ACGME
supervision guidelines. For example, a resident who performs a procedure or takes independent call must, at a minimum, be
supervised through oversight.
Answers to Frequently Asked Questions about the NAS and milestones are available on the ACGME’s NAS microsite:
http://www.acgme-nas.org/assets/pdf/NASFAQs.pdf.
4
ACGME Report Form
The diagram below presents an example set of milestones for one sub-competency in the same format as the milestone
report worksheet. For each reporting period, a resident’s performance on the milestones for each sub-competency will be
indicated by:
 selecting the level of milestones that best describes the resident’s performance in relation to the milestones
or
 selecting the “Has not Achieved Level 1” option
Selecting a response box in the middle of a
level implies that milestones in that level and
in lower levels have been substantially
demonstrated.
Selecting a response box on the line in between
columns indicates that milestones in lower levels have
been substantially demonstrated as well as some
milestones in the higher columns(s).
5
PATHOLOGY MILESTONES
ACGME Reporting Worksheet
PC1: Consultation: Analyzes, appraises, formulates, generates, and effectively reports consultation (AP and CP)
Has not
Achieved
Level 1
Level 1
Level 2
Level 3
Level 4
Understands the implications
of and the need for a
consultation
Prepares a draft
consultative report (verbal
or written)
Prepares a full consultative
report with a written
opinion for common
diseases
Observes and assists in the
consultation
Performs timely, clinically
useful consultation for
requests for products or
additional testing
Independently prepares a
full consultative written
report with comprehensive
review of medical records
on common and
uncommon diseases
Understands the concept of a
critical value and the read-back
procedure
Understands and applies
Electronic Medical Record
(EMR) to obtain added clinical
information
Understands that advanced
precision diagnostics and
personalized medicine (e.g.,
molecular diagnostic testing)
may be applied to patient care
for genetic, neoplastic and
infectious disorders, and
population health
Understands rationale for
the critical value list
Knows the critical value list
and participates in the
critical value call-back of
results
Understands the
importance of accurate,
timely, and complete
reporting of laboratory test
results
Understands the role of
specific advanced precision
diagnostics and
personalized medicine
assays, and how results
affect patient diagnosis
and prognosis, and overall
Prioritizes and presents
patient care issues for
report after call
Answers routine pathology
questions, drawing upon
appropriate resources
Applies the escalation
procedure for failed critical
value call-backs
Effectively communicates
preliminary results on
cases in progress
Understands pre-analytic
issues and quality control
for advanced precision
diagnostics and
Runs report conference
after call
Develops a portfolio of
clinical consultation
experience
Recommends new or
alternate escalation
procedures for failed
critical value call-backs as
needed
Suggests evidence-based
management, prognosis,
and therapeutic
recommendations based
on the consultation
Level 5
Proficient in pathology
consultations with
comprehensive review of
medical records
Demonstrates an
expanded portfolio of
clinical and patient care
experience with pathology
consultation
Participates in intuitional
processes of generating
the critical value list
Is proficient in consultation
regarding test utilization
and treatment decisions
based on advanced
Provides consultation, as
needed, to clinicians about
utilization and
interpretation of advanced
Copyright (c) 2013 The Accreditation Council for Graduate Medical Education and The American Board of Pathology. All rights reserved. The copyright owners grant third parties
the right to use the Pathology Milestones on a non-exclusive basis for educational purposes.
1
patient care
Comments:
Suggested Evaluation Methods: Direct observation, Retrospective peer review, Portfolio, Feedback from clinical colleagues (360 evaluations), Peer review, HIPAA training
documentation provided
2
PC2: Interpretation and reporting: Analyzes data, appraises, formulates, and generates effective and timely reports (CP)
Has not
Achieved
Level 1
Level 1
Identifies key elements in the
health care record
Level 2
Uses clinical correlation to
interpret and report test
results
Observes and assists in the
interpretation and reporting of
the diagnostic test
Describes the test platform
and methodology
Understands indications for
common tests
Accurately interprets and
reports the results
algorithms in the work-up
for common diagnoses
Level 3
Limits and focuses a
differential diagnosis
Knows the current and upto-date literature about
the test result
Prepares a differential
diagnosis for abnormal
results
algorithms in the work-up
for common and
uncommon diagnoses
Level 4
Able to lead discussion on
developing a differential
diagnosis based upon
clinical information
Interfaces with clinical
team to recommend tests,
based upon current
literature
Knows potential
confounding factors that
may contribute to
erroneous results
Understands and prudently
applies justification for
approval of costly testing
Level 5
Proficient in using health
care records and clinical
information to develop a
limited and focused
Critically evaluates and
applies the current
literature
Proficient in the
interpretation and
reporting of clinical
pathology test results in
the context of the patient’s
medical condition
Proficient in algorithms in
the work-up for all
diagnoses
Writes policies on
algorithms for testing
Comments:
Suggested Evaluation Methods: Direct observation, Simulation, Feedback from clinical colleagues (360 evaluations), Retrospective peer review, Quality management
results
3
PC3: Interpretation and diagnosis: Demonstrates knowledge and practices interpretation and analysis to formulate diagnoses (AP)
Has not
Achieved
Level 1
Level 1
Recognizes the importance of a
complete pathology report for
patient care
Level 2
Begins to make
connections between
clinical differential
diagnosis, gross, and
microscopic pathologic
findings
Generates a list of next
steps (ancillary testing; has
awareness of options
available) needed to refine
differential in the clinical
context
Distinguishes normal from
abnormal histology and
recognizes confounding
factors
Level 3
Correlates the clinical
differential diagnosis with
gross and microscopic
pathologic findings
Recognizes appropriate
ancillary tests and refines
knowledge of “next steps”
and proper utilization for
application to differential
Consistently recognizes and
correctly identifies
common histopathologic
findings (develops a "good
eye"); able to troubleshoot
(e.g., tissue artifacts,
processing and sampling
issues)
Level 4
Analyzes complex cases,
integrates literature, and
prepares a full consultative
written report with
comprehensive review of
medical records
Interprets ancillary testing
results in clinical context
Makes accurate diagnoses
reliably, appreciates the
nuances of diseases, and is
able to independently
troubleshoot confounding
factors
Level 5
Assesses, analyzes, and is
able to distinguish subtle
differences in difficult
cases
Proficient in interpretation
with comprehensive
review of medical records
Seeks appropriate
consultations
Comments:
Suggested Evaluation Methods: Direct observation, Simulation, Feedback from clinical colleagues (360 evaluations), Examination
4
PC4: Reporting: Analyzes data, appraises, formulates, and generates effective and timely reports (AP)
Has not
Achieved
Level 1
Level 1
Applies prior knowledge
and draws on resources to
learn normal gross
anatomy, histology, and
special techniques
Recognizes the role of the
surgical pathologist in the
management of patients,
including the utilization of
cancer staging
Level 2
Level 3
Attends and contributes Reliably applies knowledge
to gross and microscopic of gross and histologic
conferences
features in formulating a
diagnosis for common
entities; able to present at
Brings clinical/ancillary
information to sign-out
gross conference
(e.g., radiology, prior
Selects, orders, and
cases, reading about
interprets clinical/ancillary
case)
information to refine a
Generates preliminary
report and/or
Composes a complete and
Preliminary Autopsy
accurate report on common
Diagnosis (PAD) (for
specimens
autopsy) prior to signout with attending
Able to generate a cause of
staff/responsible
death and manner of death
physician
for autopsy
Is aware of accepted
Completes routine
standards for turnpreliminary and final reports
around time
within standards for turnaround time
Becomes familiar with
synoptic reporting
Knows when synoptic
reporting/template required
Level 4
Reliably applies knowledge
of gross and histologic
features in formulating a
diagnosis for common and
uncommon entities
Seeks appropriate
consultations
Integrates clinical/ancillary
information into report
Composes a complete and
accurate report on
common and uncommon
specimens, including
autopsies
Completes complicated
preliminary and final
reports within standards
for turn-around time
Level 5
Participates in
intradepartmental peer review
consultation with colleagues
Manages ambiguity and
uncertainty in result
interpretation and ancillary
testing
Produces timely reports with
complete accurate gross and
histopathologic findings,
including ancillary studies;
integrates evidence-based
medicine/current literature and
knowledge
Ensures communication of
results to appropriate audiences
Keeps current with evolving
standards of synoptic reporting
Communicates effectively
with family members,
when applicable
Able to complete synoptic
report accurately
Comments:
Suggested Evaluation Methods: Direct observation, Narrative, Feedback from clinical colleagues (360 evaluations), Retrospective peer review
5
PC5: Procedure: Surgical Pathology grossing: Demonstrates attitudes, knowledge, and practices that enables proficient performance of gross
examination (analysis and appraisal of findings, synthesis and assembly, and reporting) (AP)
Has not
Achieved
Level 1
Level 1
Level 2
Level 3
Level 4
Understands common
surgical procedures and
the resultant specimens
Demonstrates familiarity with the
gross manual or a similar
reference book
Applies principles of grossing
to newly encountered
specimen types
Recognizes the importance
of grossing for the
interpretation of histology
and management of
patients
Ensures and maintains the
integrity of specimens to avoid
cross-contamination or identity
mix-up
Correctly describes and
appropriately samples
common and uncommon
surgical specimens
Has a portfolio of
grossed specimens
that demonstrates
competency across a
range of complex
specimens
Correctly describes and
appropriately samples common
surgical specimens, including
necessary tissues for ancillary
studies in correct media/fixative
Recognizes when additional
gross sampling is necessary
for diagnosis or staging
Applies prior knowledge
and draws on resources to
learn normal gross
anatomy
Correlates clinical and/or
radiological information
Understands the components of
an appropriate and complete
report
Develops time management skills
Produces reports that
contain all the necessary
information for patient
management; edits
transcribed reports
effectively
Correctly describes
and appropriately
samples all specimen
types
Dictates complete,
logical, and succinct
descriptions
Level 5
Demonstrates an expanded
portfolio of competency in
grossing specimens of a
widely diverse and complex
specimen type
Proficient in the performance
of surgical pathology gross
examination
Proficient in the production
of complete, logical, and
succinct descriptions
Efficient in grossing
surgical specimens
Demonstrates increasing
efficiency in grossing
specimens
Comments:
Suggested Evaluation Methods: Direct observation, 360 evaluation, Periodic self-assessment, Narrative, Portfolio, Quality management
6
PC6: Procedure: Intra-operative consultation/ frozen sections: Demonstrates attitudes, knowledge, and practices that enables proficient performance
of gross examination, frozen section (analysis and appraisal of findings, synthesis and assembly, and reporting) (AP)
Has not
Achieved
Level 1
Level 1
Understands common
surgical procedures and
the resultant specimens
and potential intraoperative
consultation/frozen
section/intra-operative
cytology (IOC/FS)
Level 2
Is aware of indications
and contraindications
for IOC/FS and follows
protocols and
regulations
Procures tissue for
diagnosis under
supervision
Prepares IOC/FS that are
of good interpretive
quality
Understands and follows
correct call-back
guidelines
Aware of limitations of
techniques and
interpretation
Level 3
Discusses with pathology
attending staff member(s)
any requests that are
contraindicated
Correctly selects tissue for
frozen section diagnosis
independently
Able to perform high quality
IOC/FS on technically difficult
and multiple specimens;
performs IOC/FS within turnaround time standards
the diagnosis and is
cognizant of the impact of
diagnosis on patient care,
even in ambiguous situations
Demonstrates knowledge of
the limitations of techniques
and interpretation
Level 4
Appropriately and
professionally discusses
with requesting provider
any IOC/FS that is
contraindicated
Level 5
Proficient in the performance of
IOC/FS
Able to manage competing
tasks, especially in time
sensitive situations
Responds appropriately to
the concerns of the
surgeon
Given discussion of the
case with the attending
staff member(s),
communicates
appropriately with
surgeon, asking
appropriate questions that
influence diagnosis
Communicates limitations
of techniques and
interpretation to clinicians
Comments:
Suggested Evaluation Methods: Direct observation, Narrative, Feedback from clinical colleagues (360 evaluations), Retrospective peer review, Portfolio,
Quality management
7
PC7: Procedures: If program teaches other procedures (e.g., bone marrow aspiration, apheresis, fine needle aspiration biopsy, ultrasound guided FNA,
etc.) (AP/CP)
Has not
Achieved
Level 1
Level 1
Recognizes the role of the
procedure
Level 2
Participates in simulated
experience in the
procedure, including
slide preparation and
staining, if applicable
Observes and assists on
the procedure
Observes or participates
in providing support to
other service providers
performing the
procedure
Is aware of potential
complications of the
procedure and need to
obtain informed consent
Level 3
Discusses with pathology
attending staff member(s)
any requests that are
contraindicated, obtains
informed consent, and is
able to assess specimen and
procedure adequacy
Performs a "time-out"
according to standard
procedures; performs the
procedure; procures
adequate specimens, if
applicable
Provides an accurate
adequacy assessment and
triages specimens for
appropriate ancillary studies,
if applicable
Obtains informed consent
Recognizes and understands
the management of
complications of the
procedure
Level 4
Appropriately and
professionally documents
procedure and discusses
with clinical team and
manages complications
Level 5
Proficient in the performance of
the procedure
Able to perform the
procedure with minimal
supervision
Understands indications for
and/or performs
ultrasound guided Fine
needle aspiration biopsy
(FNAB) and/or core needle
biopsy, if applicable
Provides appropriate
provisional assessment
Manages complications of
the procedure or refers to
the appropriate health
care professional
Comments:
Suggested Evaluation Methods: Direct observation, Simulation
8
MK1: Diagnostic Knowledge: Demonstrates attitudes, knowledge, and practices that incorporate evidence-based medicine and promote life-long
learning (AP/CP)
Has not
Achieved
Level 1
Level 1
Identifies the resources for
learning in pathology
Level 2
Assimilates medical
knowledge in pathology
from various learning
sources
Demonstrates textbooklevel diagnostic knowledge
for pathology
Level 3
Performs scientific
literature review and
investigation of clinical
cases to inform patient
care (evidence-based
medicine) and improve
diagnostic knowledge of
pathology
Level 4
Level 5
Applies and synthesizes
medical knowledge from
scientific literature review
and investigation to inform
patient care (evidencebased medicine)
Contributes to medical
knowledge of others and
participates in life-long
learning through literature
review, Continuing Medical
Education [(CME), and SelfAssessment Modules
(SAMs)
Presents and discusses
cases
Demonstrates proficiency
Demonstrates competence in knowledge of pathology
in diagnostic knowledge of
pathology
Comments:
Suggested Evaluation Methods: Direct observation, Pre- and post-test, Rotation exams, Narrative, 360 evaluation, Board examination, Maintenance of certification/SAMs,
Resident In-Service Examination (RISE) and Pathologist Recertification Individualized Self-Assessment Exam (PRISE)
9
MK2: Teaching: Demonstrates ability to interpret, synthesize, and summarize knowledge; teaches others (AP/CP)
Has not
Achieved
Level 1
Level 1
Participates in active learning
Level 2
Understands and begins to
acquire the skills needed
for effective teaching
Teaches medical students,
as needed
Level 3
Teaches peers as needed
Level 4
Teaches across
departments and at all
levels, including to
clinicians, patients, and
families
Level 5
Models teaching across
departments and at all
levels, including for
clinicians, patients, and
families
Comments:
Suggested Evaluation Methods: Direct observation, 360 evaluations, Teaching evaluations, Student performance on exams, Simulations, Conference presentation
evaluation portfolio
10
MK3: Procedure: Autopsy: Demonstrates knowledge and practices that enable proficient performance of a complete autopsy (analysis and appraisal of
findings, synthesis and assembly, and reporting) (AP)
Has not
Achieved
Level 1
Level 1
Level 2
Understands the principles
of confidentiality, universal
precautions, chemical
hazards, and personal
protective equipment
Properly identifies the
decedent and verifies consent
and limitations to extent of the
autopsy
Understands the value of
an autopsy
Able to perform all seven
aspects of a routine autopsy
Concisely reviews and presents
clinical records/history;
contacts the clinical team in
advance of the case and
summarizes questions posed by
the clinical team
Is aware of reporting
regulations, such as legal
jurisdiction, statutes regarding
authorization to perform
autopsy (medical examiner),
device reporting,
communicable diseases
Level 3
Able to plan and perform
complex/difficult cases
Assists in preparation of
presentations for
morbidity and mortality
(M&M), Clinical Pathologic
Conference (CPC), or other
conferences
Understands chain of
custody, the elements of
scene investigation, trace
evidence, and court
testimony
Level 4
Level 5
Performs uncomplicated
gross dissection within four
hours
Proficient in the
performance of a complete
autopsy and in reporting
the results in a timely
manner
Presents results at M&M,
CPC, or other conferences,
and effectively answers
clinical questions
Assesses and applies chain
of custody, interprets the
elements of scene
investigation, trace
evidence, and court
testimony
Proficient in the
presentation of results at
M&M, CPC, or other
conferences, and in
answering clinical
questions
Proficient in the discussion
of the chain of custody,
and interpretation and
assessesment of the
elements of scene
investigation, trace
evidence, and giving court
testimony
Comments:
Suggested Evaluation Methods: Direct observation; Feedback from clinical colleagues (360 evaluations), Narrative, Portfolio review, Quality management; Peer evaluation
11
SBP1: Patient safety: Demonstrates attitudes, knowledge, and practices that contribute to patient safety (AP/CP)
Has not
Achieved
Level 1
Level 1
Understands the importance of
identity and integrity of the
specimen and requisition form
and verifies the identity
Understands the risk inherent
in hand-overs
Level 2
Consistently checks
identity and integrity of
specimen
Independently obtains
clinical information when
needed
Explores other resources
such as EMR and radiology
Level 3
Trouble-shoots preanalytic problems, as
needed, with minimal
supervision, including
deviations from policies
(waivers)
Follows patient safety
policies and accreditation
requirements
Level 4
Trouble-shoots patient
safety issues (including
pre-analytic, analytic, and
post-analytic), as needed,
without supervision
Level 5
Models patient safety
practices
Writes and implements
policies on patient safety,
as needed
Completes an advanced
MOC patient safety
module
Handles deviations from
policies (waivers) with
supervision
Performs hand-overs in an
appropriate manner,
according to guidelines
(e.g., SituationBackground-AnalysisRecommendation [SBAR]
or local guidelines)
Comments:
Suggested Evaluation Methods: Direct observation, Narrative, QA reports (misidentification rates, amended report rates), Transfusion committee
results/work-ups, Documentation provided
12
SBP2: Lab Management: Regulatory and compliance: Explains, recognizes, summarizes, and is able to apply regulatory and compliance issues (AP/CP)
Has not
Achieved
Level 1
Level 1
Level 2
Knows that laboratories must
be accredited
Knows accrediting agencies
of the laboratory
Can define appropriate
disclosure of protected health
information (PHI) as defined by
the Health Insurance Portability
and Accountability Act (HIPAA)
Is aware of requirements
for institutional review for
human experimentation
(research) and
biospecimen donation
Understand and apply
policies and procedures
inPHI as defined by HIPAA
Level 3
Understands the
components of lab
accreditation and
regulatory compliance
(Clinical Laboratory
Improvement
Ammendments [CLIA] and
others), either through
training or experience
Confirms institutional
review board approval
prior to biospecimen
procurement
Completes laboratory
inspector training
Understands ICD9 (ICD10)
coding and the need to
document appropriately in
reports
Level 4
Level 5
Understands the
components and processes
for credentialing and
privileging
Participates in and
complies with ongoing and
focused competency
assessment
Participates in an internal
or external laboratory
inspection
Participates in or leads
internal or external
laboratory inspections
Able to correctly use
Current Procedural
Terminology (CPT) and
ICD9 (ICD10) codes for
billing purposes;
understands elements of a
compliance plan
Participates in institutional
review process, as needed
Creates and follows a
compliance plan
Uses best practices for
billing compliance
Assists colleagues as
needed with policies and
procedures of PHI as
defined by HIPAA
Teaches allied health
professionals and clerical
staff as necessary about
the policies and
procedures of PHI as
defined by HIPAA
Comments:
Suggested Evaluation Methods: Direct observation, Portfolio, Simulation, Examination, Team leader performance evaluation, Portfolio review, Quality
management; Peer evaluation
13
SBP3: Lab Management: Resource Utilization (personnel and finance): Explains, recognizes, summarizes, and is able to apply resource utilization
(AP/CP)
Has not
Achieved
Level 1
Level 1
Interprets an organizational
chart and is aware of
employment contracts and
benefits
Describes a budget
Level 2
Knows the personnel and
lines of reporting in the
laboratory
Recognizes different
budget types (i.e., capital
vs. operating budget)
Understands the basics of
pathology practice finance
(e.g., Part A and Part B,
Centers for Medicare &
Medicaid Services [CMS])
Level 3
Understands and describes
the process of personnel
management and
employment laws (e.g.,
interview questions, Family
and Medical Leave Act,
termination policies)
Understands key elements
of hospital and laboratory
budgets
Level 4
Creates a basic job
description and
participates in employee
interviews/performance
evaluation (real or
simulated experiences)
Level 5
Manages personnel
effectively
Develops and manages a
laboratory budget
Participates in a budget
cycle exercise (draft,
defend, and propose
logical cuts and/or
additions)
Comments:
Suggested Evaluation Methods: Direct observation, Portfolio, Simulation, 360 evaluation, Analysis of resident evaluations (meeting, employee interview, difficult
conversations)
14
SBP4: Lab Management: Quality, risk management, and laboratory safety: Explains, recognizes, summarizes, and is able to apply quality improvement,
risk management and safety issues (AP/CP)
Has not
Achieved
Level 1
Level 1
Participates in basic safety
training (e.g., Occupational
Safety and Health
Administration [OSHA], blood
borne pathogen, personal
protective equipment)
Level 2
Participates in laboratory
specific safety training
(e.g., sharps disposal,
proper equipment
utilization)
Understands when and
how to file an incident or
safety report
Understands the concept
of a laboratory quality
management plan
Level 3
Level 4
Interprets quality data and
charts and trends
Has completed a quality
improvement project
Understands continuous
improvement tools, such
as Lean and Six Sigma
Reviews and analyzes
proficiency testing results
Understands serious
reportable events (SREs)
and appropriate reporting,
and participates in root
cause analysis (RCA)
Participates in department
and hospital-wide quality,
risk management, and
safety initiatives
Level 5
Utilizes continuous
improvement tools, such
as Lean and Six Sigma
Manages laboratory
quality assurance and
safety
Demonstrates a knowledge
of proficiency testing and
its consequences
Attends and participates in
quality improvement
meetings
Comments:
Suggested Evaluation Methods: Direct observation, Portfolio, Simulation, Narrative, Examination, 360 evaluations
15
SBP5: Lab Management: Test utilization: Explains, recognizes, summarizes, and is able to apply test utilization (AP/CP)
Has not
Achieved
Level 1
Level 1
Is aware of the test menu and
rationale for ordering
Level 2
Organizes basic data for
utilization review
Identifies key elements of
ordering practices
Able to understand
appropriate ordering or
inappropriate ordering and
over-utilization
Level 3
Able to interpret charts
and graphs that
demonstrate utilization
patterns
Intervenes in inappropriate
or over-utilization
situations
Level 4
Able to create charts and
graphs that demonstrate
utilization patterns
(simulated or real
experiences)
Maintains a portfolio that
includes experience in test
utilization reviews and
interventions that drive
change
Level 5
Demonstrates a broad
portfolio of analyses for
utilization reviews in
complex scenarios and
team management to drive
change in areas both
within and outside of the
department
Comments:
Suggested Evaluation Methods: Direct observation, Portfolio, 360 analysis, Simulation
16
SBP6: Lab Management: Technology assessment: Explains, recognizes, summarizes, and is able to apply technology assessment (AP/CP)
Has not
Achieved
Level 1
Level 1
Understands the value of new
technology
Level 2
Level 3
Understands the need for a
process in implementing
new technology
Understands and describes
the process of
implementing new
technology
Aware of cost-benefit
analysis for new
technology
Able to perform a costbenefit analysis
Level 4
Participates in new
instrument and test
selection, verification,
implementation, and
validation (including
reference range analysis)
and maintains a portfolio
of participation in these
experiences
Level 5
Acts as primary assessor
for new technology and is
able to lead efforts to
optimize test utilization
and resource management
Comments:
Suggested Evaluation Methods: Direct observation, Portfolio, Simulation
17
SBP7: Informatics: Explains, discusses, classifies, and applies clinical informatics (AP/CP)
Has not
Achieved
Level 1
Level 1
Demonstrates familiarity with
basic technical concepts of
hardware, operating systems,
and software for general
purpose applications
Level 2
Understands lab specific
software, key technical
concepts and subsystems
on interfaces, workflow,
barcode application,
automation systems
(enterprise systems
architecture)
Level 3
Level 4
Applies informatics skills as
needed in project
management (data
management,
computational statistics)
Participates in operational
and strategy meetings,
apprentices
troubleshooting with IT
staff, applies informatics
skills in laboratory
management and
integrative bioinformatics
(able to aggregate multiple
data sources and often
multiple data analysis
services)
Level 5
Is proficient in medical
informatics systems
Able to assess and
purchase a laboratory
information system for
anatomic and/or clinical
pathology laboratories
Able to utilize medical
informatics in the direction
and operation of the
laboratory
Comments:
Suggested Evaluation Methods: Direct observation, 360 evaluation, Portfolio data
18
PBLI1: Recognition of errors and discrepancies: Displays attitudes, knowledge, and practices that permit improvement of patient care from study of
errors and discrepancies. (AP/CP)
Has not
Achieved
Level 1
Level 1
Acknowledges and takes
responsibility for errors when
recognized
Level 2
Recognizes limits of own
knowledge
Initiates self-reflection
process, (e.g., as evidenced
in self-assessment
interviews with program
director)
Level 3
Reflects upon errors in a
group setting (such as
M&M type conference
setting)
Participates in root cause
analysis (RCA)
Level 4
Level 5
Demonstrates significant
awareness of own blind
spots
Models use of errors and
discrepancies to improve
practice
communication of
error/discrepancies to
clinicians
Provides immediate
communication of
error/discrepancies to
clinicians
Comments:
Suggested Evaluation Methods: Self-assessment (written and verbal), Direct observation, Narrative
19
PBLI2: Scholarly Activity: Analyzes and appraises pertinent literature, applies scientific method to identify and interpret evidence-based medicine and
apply it clinically (AP/CP)
Has not
Achieved
Level 1
Level 1
Utilizes and applies basic texts
Uses presentation software,
online literature databases, and
searches as needed
Demonstrates working
knowledge of basic statistical
analysis
Level 2
Level 3
Level 4
Level 5
Develops knowledge of the
basic principles of research
(demographics,
Institutional Review Board
[IRB], human subjects),
including how research is
conducted, evaluated,
explained to patients, and
applied to patient care
Critically reads and
incorporates the medical
literature into
presentations and lectures
Critically examines
literature for study design
and use in evidence-based
clinical care
Proficient in critical
evaluation of the literature
and participates in life-long
learning
Applies knowledge of the
basic principles of research
Identifies gaps in the
currently available
knowledge
Adds to a portfolio of
scholarly activities, which
may include manuscript
preparation, abstract
presentation at a local,
regional or national
meeting, or other scientific
presentation
Has a well developed
portfolio of scholarly
activities
Comments:
Suggested Evaluation Methods: Direct observation and evaluation of presentations by participants, Portfolio, Examination
20
PROF1: Licensing, certification, examinations, credentialing: Demonstrates attitudes and practices that ensures timely completion of required
examinations and licensure (AP/CP)
Has not
Achieved
Level 1
Level 1
Level 2
Level 3
Completes and passes Step 2CK
and 2CS of United States
Medical Licensing Examination
(USMLE)
Completes and passes Step
3 of USMLE
Performs at expected level
on objective examinations
Performs at expected level
on objective examinations
Demonstrates expanded
portfolio and reviews with
program director at semiannual evaluation
Begins assembling
portfolio of experiences,
including case log and
participation in
administrative tasks
Level 4
Level 5
Applies for full and
unrestricted medical
license
Obtains full and
unrestricted medical
license
Demonstrates complete
portfolio and reviews with
program director at semiannual evaluation
Board-eligible/Boardcertified and begins to
participate in maintenance
of certification (SAMS, etc.)
Maintains portfolio
Comments:
Suggested Evaluation Methods: Documentation provided
21
PROF2: Professionalism: Demonstrates honesty, integrity, and ethical behavior (AP/CP)
Has not
Achieved
Level 1
Level 1
Behaves truthfully and
understands the concepts
of ethical behavior,
occasionally requiring
guidance; seeks counsel
when ethical questions
arise
Understands the concepts
of respect, compassion,
and empathy
Level 2
Is truthful,
acknowledges personal
near misses and errors,
and puts the needs of
patients first
Engages in ethical
behavior
Observes patient
confidentiality
Manifests sensitivity to
patient's fears and
concerns
Level 3
Level 4
Demonstrates truthfulness
to all members of the health
care team
Exemplifies truthfulness to
all members of the health
care team
Identifies, communicates,
and corrects errors
Serves as a role model for
members of the health
care team in accepting
personal responsibility
Demonstrates respect,
compassion, and empathy,
even in difficult situations
Puts the needs of each
patient above his or her
own interests
Level 5
Models truthfulness to all
members of the health care
team; is viewed as a role model
in accepting personal
responsibility by members of
the health care team; and
always puts the needs of each
patient above his or her own
interests
Models respect, compassion,
and empathy, in complex
situations
Promotes respect,
compassion, and empathy
in others
Demonstrates respect,
compassion, and
empathy to all
Comments:
Suggested Evaluation Methods: Direct observation, 360 evaluation
22
PROF3: Professionalism: Demonstrates responsibility and follow-through on tasks (AP/CP)
Has not
Achieved
Level 1
Level 1
Completes assigned tasks
on time
Level 2
Dependably completes
assigned tasks in a
timely manner
Level 3
Anticipates team needs and
assists as needed
Assists team members
when requested
Respects assigned
schedules
Level 4
Anticipates team needs
and takes leadership role
to independently
implement solutions
Level 5
Exemplifies effective
management of multiple
competing tasks, including
follow-through on tasks
Is source of support/guidance to
other members of health care
team
Comments:
Suggested Evaluation Methods: Direct observation, 360 evaluation, Portfolio data (e.g., autopsy TAT)
23
PROF4: Professionalism: Gives and receives feedback (AP/CP)
Has not
Achieved
Level 1
Level 1
Receives feedback
constructively
Level 2
Accepts feedback
constructively and
modifies practice in
response to feedback
Level 3
Able to provide constructive
feedback
Level 4
Exemplifies giving and
receiving constructive
feedback
Encourages and actively
seeks feedback to improve
performance
Level 5
Models giving and receiving
constructive feedback
Encourages and actively seeks
feedback to improve
performance
Comments:
Suggested Evaluation Methods: Direct observation, 360 evaluation, Role-play or simulation, Resident experience narrative
PROF5: Professionalism: Demonstrates responsiveness to each patient’s unique characteristics and needs (AP/CP)
Has not
Achieved
Level 1
Level 1
Respects diversity,
vulnerable populations,
and patient autonomy
Level 2
Embraces diversity and
respects vulnerable
populations
Is aware of potential for
bias or cultural
differences to affect
clinical care
Level 3
Level 4
Demonstrates cultural
competency
Exemplifies cultural
competency
Identifies and avoids biases,
and recognizes cultural
differences that may affect
clinical care
Identifies and avoids
biases, and recognizes
cultural differences that
may affect clinical care
Level 5
Models cultural competency
Works with peers to avoid
biases
Recognizes cultural differences
that may affect clinical care
Comments:
24
PROF6: Professionalism: Demonstrates personal responsibility to maintain emotional, physical, and mental health (AP/CP)
Has not
Achieved
Level 1
Level 1
Level 2
Is aware of importance of
emotional, physical, and
mental health and issues
related to fatigue/sleep
deprivation
Manages emotional,
physical, and mental
health and issues related
to fatigue/sleep
deprivation
Exhibits basic professional
responsibilities, such as
timely reporting for duty
rested, readiness to work,
and being appropriately
dressed
Recognizes signs of
impairment, and seeks
appropriate help when
needed
Level 3
Manages emotional,
physical, and mental health
and issues related to
fatigue/sleep deprivation,
especially in stressful
conditions
Level 4
Recognizes signs of
impairment in self and
others, and facilitates
seeking appropriate help
when needed
Level 5
Accesses institutional resources
to address impairment, and
initiates seeking appropriate
help when needed
Anticipates and avoids
behaviors that might lead
to impairment
Comments:
25
ICS1: Intra-departmental interactions and development of leadership skills: Displays attitudes, knowledge, and practices that promote safe patient
care through team interactions and leadership skills within the laboratory (AP/CP)
Has not
Achieved
Level 1
Level 1
Demonstrates respect for and
willingness to learn from all
members of the pathology
team
Is aware of the significance of
conflict in patient care
Level 2
Works effectively with all
members of the pathology
team
Attends laboratory,
departmental, or
institutional committee
meetings
Aware of the mechanisms
for conflict resolution
Participates in a
cytopathology team with
cytopathologists,
cytotechnologists and lab
assistants, or surgical
pathology team with
surgical pathologists,
histotechnicians and lab
assistants or clnical
pathology team with the
pathologist, clinical
laboratory scientists and
lab assistants
Level 3
Understands own role on
the pathology team, and
flexibly contributes to
team success through a
willingness to assume
appropriate roles as
needed
Understands the basics of
running a meeting
Utilizes mechanisms for
conflict resolution and
helps to defuse and
ameliorate conflict
Participates in groups to
accomplish goals
Level 4
Helps to organize the
pathology team to
facilitate optimal
communication and coeducation among
members
Demonstrates the ability to
lead and run an effective
meeting
Level 5
Leads the pathology team
effectively
Models respect for others
Models effective conflict
prevention and resolution
skills
Participates effectively in
conflict resolution
Demonstrates ability to
lead groups to reach a
consensus and accomplish
goals
Comments:
Suggested Evaluation Methods: Direct observation, 360 evaluation, Narrative
26
ICS2: Inter-departmental and Health care Clinical Team interactions: Displays attitudes, knowledge, and practices that promote safe patient care
through interdisciplinary team interactions (AP/CP)
Has not
Achieved
Level 1
Level 1
Recognizes the importance of
clinical input in formulating a
differential diagnosis and
composing a final diagnosis
Is aware that multi-disciplinary
conferences are used to further
appropriate patient care
Is aware of pathologist’s role in
the clinical team
Understands utility of
communication with other
members of the clinical team
Level 2
Participates through
observation and active
interaction with clinicians
to obtain relevant clinical
and/or radiologic data
Attends multidisciplinary
conferences
Recognizes the importance
of timely production of a
final diagnosis and the role
it plays in patient care
Appropriately triages
requests for information
from the clinical team
Is aware of the limitations
of own knowledge
Level 3
Assesses, analyzes, and
interprets pathology
reports and is able to
discuss findings in
consultation with clinical
colleagues
Prepares and presents
cases at multidisciplinary
conferences
Responds to inquiries from
the clinical team to
contribute to patient care
clinically significant or
unexpected values,
including critical values
Is aware of the limitations
of medical knowledge
Comments:
Suggested Evaluation Methods: Direct observation, 360 evaluation, Narrative
Level 4
Level 5
Routinely interfaces with
clinical colleagues to
formulate a narrow
differential diagnosis and
arrive at a final diagnosis
Fully participates as a
member of the health care
team, and is recognized as
proficient by peers and
clinical colleagues
Can lead multidisciplinary
conferences
Organizes and is
responsible for
multidisciplinary
conferences
Knows how subtleties may
impact or alter patient
care; recognizes and uses
nuances in the proper
wording in the discussion
of pathology findings
communication with the
clinical team to contribute
to patient care
Communicates the
limitations of medical
knowledge
Serves as a consultant to
the health care team
CONFERENCE SCHEDULE
AND RESPONSIBILITIES
CONFERENCE SCHEDULE
12:00pm
Seminars in Laboratory
Medicine*
7:00am
AP Didactic
Conference/Unknown Surgical
Pathology Slide Conference *
Hematopathology Flow
Conference**
Monday
11-12pm
Tuesday
*
**
***
****
@
+
++
+++
#
##
###
Weekly
Totten Room, Scaife
618
~Every other
week (see
schedule)
Every other
week
CLB Room 9018
Hematopathology Journal Club*,
***,###
12:00pm
Patient Safety & Risk
Management in
Hematopathology Conference*,
###
CP Didactic Conference*
Every other
week
PUH G323
Weekly
CLB Room 1021
8:30am
Hematopathology Conference
(case presentation)* ***, ###
1 -3 , 5 Week
of the month
8:30am
Molecular/ Hematopathology
Conference
4 week of the
month
Totten Room, Scaife
618
10:30am
Hematology Lab Operations++
Bi-Weekly (see
schedule)
CLB 6 Floor Room
6032
12:00pm
Department Research Seminar
Weekly
PUH 11 Floor
12:00pm
Cutaneous Lymphoma Journal
Club
Last Wednesday
of the Month
12:00pm
Anatomic Pathology Grand
Rounds *
Weekly
Medical Arts Building
3708 Fifth Avenue
5th Floor, Suite
500.79 (Conference
Room A - 500.81)
Room 1104 A & B
Scaife Hall
4:00pm
CHP Tumor Board
Leukemia Conference
Molecular QA Conference
st
1:00pm2:30pm
+++, ***
rd
th
th
Wednesday
Friday
CLB Room 1021
12:00pm
7:00 am
Thursday
Weekly
+
Totten Room, Scaife
618
Totten Room, Scaife
618
th
th
st
1 Thursday of
the month
Weekly
Rangos Res. Bldg Lawrenceville
th
CLB 8 Fl conference
room
Attendance for residents required either based on this rotation or departmental expectations.
Attendance at this conference is strongly encouraged for trainees (but not required).
The trainees will be expected to present at these conferences.
Attendance is strongly encouraged when hematopathology cases are being presented (be sure you are getting email
notifications).
Attendance not expected.
Attendance optional.
Attendance is required for residents on laboratory medical rotation.
Attendance is expected for trainees doing pediatric hematopathology.
See description concerning attendance obligations.
Attendance required when on laboratory hematology rotation and encouraged when on other parts of hematology
rotation. One presentation required (see schedule).
Attendance required for fellows
RESIDENT AND FELLOW CONFERENCE RESPONSIBILITIES
MONDAY
12:00PM (Weekly)
Seminars in Laboratory Medicine are case presentations/lectures by residents, fellows and
faculty. See Conference Schedule from Laboratory Medicine Office for topics.
TUESDAY
7:00AM
The AP Didactic Conference/Unknown Surgical Pathology Slide Conference takes place on
Tuesdays from 7:00 to 9:00 AM in the Totten Room. The slides and clinical history for the
conferences when they occur will be available at PUH, Shadyside and Magee for preview
at least one week prior to the conference. The schedule is available on the resident website
(http://residents.pathology.pitt.edu/default.aspx). Fellows may attend; however it is not
required and hematopathology duties take precedence. Breakfast is served.
8:30AM
SHY Adult Bone Marrow Review takes place Tuesdays from 8:30 – 9 am. A few cases selected
by the Hematology/oncology attending and fellow are presented via teleconference using Go to
Meeting (complete instructions posted in G304). The cases will be presented by the attending
pathologist on BM service 3, or the hematopathology fellow on BM service 2 with the BM3
attending pathologist serving as a mentor.
9:15AM
Continuing Education in Clinical Chemistry and Hematology Conference takes place
Tuesdays at 9:15 -10:15am (following the residents' lectures). The location is usually CLB
room 1021. Each resident on the laboratory hematology rotation will present once.
The sessions are targeted toward technologist education. Discussion between
pathologists/trainees is encouraged. Periodic updating of important basic concepts is
welcome. Please seek input from Dr. Contis when planning your hematology presentation.
11:00AM (several times/month)
The Flow Cytometry Conference is a time when interesting flow cytometry cases selected by
the technologists are reviewed and discussed by one of the hematopathologists. Some
conferences are used for didactic presentations on a specific topic. Generally, other
hematopathologists, residents and fellows attend. No preparation is required. See
schedule for dates of conference. (CLB, Room 9018)
12:00PM
Approximately twice per month, residents doing Hematopathology will be asked to select one (1)
current journal article for presentation at our Journal Club (see separate schedule). The
selection should be of interest to the presenter and others in the group and needs to be
approved by the faculty member or fellow responsible for that date (see schedule for
dates and trainee/faculty assignments). If requested, the faculty member can also offer
suggestions for appropriate articles or offer additional advice in making a selection. The
faculty person or fellow will also choose and present an article. The articles should be
emailed to the hematopathology secretary, Jessica Klimkowicz, no later than Thursday
preceding the Journal Club.
In terms of presentation, it is important to provide enough background information to help explain
why the study was done and /or may be important and how it relates to what is already
known. Any detailed discussion of methodology that may be required should be done
when the results are presented. When presenting the results, it is important to go over the
various tables and figures in the paper and also point out any problems that may be
presented in the data or methodology. Finally, the ultimate significance of the study given
the results found should be discussed. PowerPoint presentations are not at all necessary
and are discouraged!
Everyone attending should also be prepared to comment on the above issues so that a lively
discussion will ensue.
On all other Tuesdays, there will be a Patient Safety and Risk Management Conference (see
separate schedules). Cases are presented and discussed that could potentially raise
patient safety and risk management issues. For example, cases that are particularly prone
to diagnostic errors or cases of entities seen so infrequently that pathologists might not be
familiar with them would be of particular interest. Cases where there have been any types
of errors made within or outside our institution would also be of particular value. Trainees,
along with faculty members, may bring cases to show.
WEDNESDAY
7:00AM
CP Didactic Conference is a set of lectures covering all of laboratory medicine, some
pertinent to hematopathology. The schedule is available on the resident website.
(http://residents.pathology.pitt.edu/default.aspx).
8:30AM
The Hematopathology Conference is entirely the responsibility of our division. The purpose is
to provide a forum to go over morphologic, immunophenotypic, karyotypic, and genotypic
issues together with their clinical correlates. We present 5 cases each week at conference,
ideally 3-bone marrow (including Children’s cases) and 2 lymph nodes. The conference
responsibilities include:
Trainees on the adult bone marrow service will consult with faculty signing out marrows no later
than Friday and choose 3 interesting and /or educational marrows. As at least one
pediatric marrow should be presented if there is a trainee on the service, trainees on the
adult marrow service need to consult with the pediatric service to be sure that 3 bone
marrows/PB/ATL cases are being presented. Please do not add additional cases if there
are already 5.
A.
After cases are selected, please sign-up by giving name and number to the bone marrow
technologist or leaving a voicemail message on the Audix line (802-3273). NAMES
MUST BE SUBMITTED BY THE END OF MONDAY.
The trainees will take images using one of the digital camera set-ups in the Division of
Hematopathology (room G304 conference room or G323 lymph node sign-out room) and
find out the case history from the physician or the chart. The images should be imported
into a PowerPoint presentation. At the conference, the trainees will present the case
including a brief history, any prior material and any ancillary studies at the conference. In
addition, some interesting aspects of the case may be discussed briefly (e.g. implications
of an unusual morphologic appearance, significance of unusual phenotype). Don’t give a
lecture. Cytogenetics will be presented by the cytogenetics laboratory faculty or by a
trainee rotating in Cytogenetics. Fellows are expected to present their own cytogenetic
findings as long as the laboratory emails them the karyotypes/FISH images to show and a
cytogeneticist can assist when needed. Genotypic results are usually presented by the
Division of Molecular Diagnostics. If no trainee is on the service, the cases are presented
by the faculty member. Case presentations including all ancillary studies should be less
than 8 minutes to allow time for discussion.
B.
Trainees on the lymph node service will consult with the faculty member signing out lymph
nodes and select two lymph node cases to present. In the absence of appropriate current
cases, older educational cases may be selected. The trainees will take images of the case and
if at all possible get the history from the chart or physician. At the conference, using
PowerPoint the trainee will present the case including a brief history, the pathology and any
ancillary studies.
C.
Remember case presentations must be relatively brief, to the point and interesting both to
pathology trainees and clinicians. If possible try to present cases in an interactive fashion.
(Totten Room, Scaife 618)
D.
If there is >1 trainee on a service, the presenting obligations should be shared.
Guidelines for PowerPoint Presentations
1.
Keep the presentation simple. Your time is better spent reading about the case
rather than having multicolored images flying around.
2.
Try to limit the number of images shown- make sure that each image makes a point.
3.
Photomicrographs should occupy the entire screen.
4.
Please use images that are in focus.
5.
No more than two flow histograms should be on a single screen (or just use the
electronic overhead projector).
6.
Up to 4 immunostains may be presented in a single screen. It is unnecessary to
illustrate all immunostains- you need to choose critical ones or ones that are
necessary to make your point. For example, please don’t show a series of 5
negative stains.
7.
Laboratory results can either be discussed or, if presented on a screen, must have
not only the numerical results, but also the units and preferably the normal ranges.
The lab results that are presented visually do not need to include every single
laboratory test that was done on the patient.
8.
In at least most cases, there is no need to present a written bone marrow
differential.
12:00PM
Trainees are encouraged, but not required to attend the Departmental Research Conference.
12:00PM
UPMC-Shadyside Tumor Board. Cases are presented by the hematopathology fellow or if
necessary by a hematopathology faculty member at the request of a clinician (detailed
procedure on page 22) (Shadyside West Wing Auditorium). Residents do not attend.
THURSDAY
8:00AM
A Pediatric Bone Marrow Case Conference is held via teleconference to the Children’s
Hospital, Lawrenceville except for the first Thursday of the month. This is attended
primarily by the pediatric hematology/oncology fellows, and the pathology trainees on the
pediatric bone marrow service. The bone marrow technologists will collect the cases from
the prior week to be presented by the attending hematopathologist on service. Fellows
may be expected to present the cases. Complete instructions for using Go-To-Meeting are
in the pediatric bone marrow signout room G304,
12:00PM
Residents doing hematopathology are expected to attend Anatomic Pathology Grand Rounds.
4:00PM
Pediatric Leukemia Tumor Board is held the first Thursday of the month from 4:00 to 5:00 in
Conference Rooms B123 and B124, Floor B, at Children’s Hospital of Pittsburgh. The
hematopathologists and bone marrow technologists are notified by e-mail the week of the
conference as to which cases are to be presented. The bone marrow technologists will
collect the cases for the trainees. The trainees will capture images and prepare a
PowerPoint presentation. The presentations should be brief and succinct and include 1
slide of peripheral smear, 1-2 slides of aspirate, and 1-2 slides of biopsy as well as any
pertinent cytochemical or immunohistochemical stains. Flow images can also be presented
– please check with attending regarding specific images to present. Pertinent results from
the cytogenetics and/or molecular studies should be summarized in 1-2 slides. The
presentation should be approved by the attending prior to presentation.
Additional information regarding Shadyside Tumor Board Conference
Wednesday Noon
Contact Person SHY:
Melissa Forkey
412-648-6466
Contact Person PUH:
Celina Fortunato
412-647-0263
1.
UPMC – Shadyside will call the UPMC – Presbyterian bone marrow lab at 6470263 with a list of patient names NO LATER THAN the Friday preceding the
conference (preferably earlier).
2.
The Bone Marrow Technologist will inform the presenter.
a. First inform the 2nd year fellow if there is one. If the 2nd year fellow cannot
present (i.e. on a rotation that precludes their availability), the fellow must
inform the bone marrow technologists immediately. Go to step b.
b. Next, inform the 1st year fellow. If the 1st year fellow cannot present (i.e. on a
rotation that precludes their availability), the fellow must inform the bone
marrow technologist immediately. Next inform the second 1st year fellow if
there is one. If there is more than one second year fellow or more than one firstyear fellow, please ask the one not on a diagnostic signout service first to do
the tumor board (unless they are on another service that would preclude their
being able to attend). If this fellow also cannot present, go to step c.
c. If no fellow can present, the bone marrow technologist will inform the
pathologist on the lymph node service for the week it is to be presented.
This way the bone marrow technologist will know who exactly will be presenting the
conference.
3.
The bone marrow technologist will pull the slides and print the reports.
4.
If surgical pathology cases are requested, the bone marrow technologist will notify
Melissa Forkey who will make other arrangements for the cases to be presented by
surgical pathologist.
5.
The bone marrow technologist will inform the person responsible for the
presentation – prior to the weekend – that the cases are ready.
6.
The bone marrow technologist will record on the log sheet that the cases are ready
and the presenter is notified.
The bone marrow technologist will call Melissa Forkey and inform her who will be presenting the case.
Pediatric Hematopathology
and General/Special
Hematology Laboratory
Experience
Pediatric Hematopathology and General/Special Hematology Laboratory
Experience (3 weeks)
Trainees should report to the pathologist signing out CHP bone marrows. The pathologist
covering the general hematology laboratory (“ATL” service) is usually the same person; if this
person is different from the one signing out CHP bone marrows, then contact him or her also.
Also, trainees should contact Dr. Contis regarding their continuing education conference
presentation at the beginning of their rotation. Residents also will discuss with Dr. Contis or
her designee how to best apportion their time in the laboratory and how to gain in-laboratory
experience with the technologists.
Pediatric Hematopathology Experience
1. Review Blood Cell Morphology. (Published by the ASCP). RBC, WBC, Normal and Abnormals
(Binders with CDs available in G304 and slides are also on resident’s shared drive, under “CP
Didactic Lectures\Previous CP Didactic Lectures\Hemepath\ASCP Hematology Images.” Each set
is a separate PowerPoint file and the key and reading material for all 6 sets of images are in the
PDF).
2. In the first week, touch base with the lead technologist Celina Fortunato to schedule a
teaching session with the bone marrow technologists (typically Tuesday afternoon is best)
to review peripheral blood and bone marrow aspirate smears
3. Pediatric Bone Marrow Sign out.
A. Preview and sign out cases with hematopathology faculty in a fashion analogous to
procedures followed with adult bone marrows.

Meet with faculty on service to coordinate these activities.

See also “Policy for sign-out of CHP marrows that have biopsies”.
4. Review of specimens from Automated Testing Laboratory and Flow Cytometry Laboratory
A. Preview and sign out pediatric and adult abnormal peripheral blood films and body fluid slides
sent for review with ATL faculty hematopathologist. Gather relevant clinical and pathology
information (such as cytology results) prior to sign-out.
B. If there is a case with interesting findings, please give the slide and copy of the ATL review
sheet to Dr. Djokic in order to contribute to the study sets.
5.
Review of selected cases of Hemoglobinopathies with the CAP textbook
Trainees should pre-review the HPLC tracings that are being faxed weekly to our division
and they should contact Dr. Dobrowolski and meet with him once at Children’s Hospital
(CHP) to review the cases with him.
6. Review of educational materials
A. Swerdlow SH, Collins RD Pediatric Hematopathology, Churchill Livingstone, 2001.
B. Nathan, DG and Orkin, SH, Nathan and Oski’s Hematology of Infancy and Childhood, 7th
Edition, WB Saunders, 2009.
C. Penchansky L, Pediatric Bone Marrow, Springer, 2004.
D. Glassy EF. Color Atlas of Hematology, CAP 1998
E. Peripheral smear and fluid slide study sets are available for checkout from Office Secretary –
G306.
F. Chromogram information for hemoglobinopathy information (in supplemental materials)
G. Bain BJ. Haemoglobinopathy Diagnosis, 2nd ed. Blackwell, 2006.
H. Schuman GB, Friedman SK. Wet Urinalysis, ASCP, 2003.
I.
Galagan, K. Color Atlas of Body Fluids: An Illustrated Field Guide Based on Proficiency
Testing.
J. Proytcheva, M.A. (Ed), Diagnostic Pediatric Hematopathology, 2011.
7. Review results of ancillary procedures performed on marrows you have reviewed and read
addenda faculty have issued.
Policy for sign-out of CHP marrows that have biopsies
1.
Hematopathology signs out biopsies on hematologic disease cases including non-Hodgkin
lymphomas. CHP surgical pathology signs out the biopsies on tumor cases.
2.
On all cases with a biopsy, the histologic section must be reviewed by the hematopathologist
even if it is not a case where the hematopathologist is signing out the biopsy. This is to ensure
that it does not conflict with the aspirate smear evaluation.
3.
In all cases with a biopsy, where CHP is signing out the biopsy the hematopathologist should
correlate with the CHP pathology report to make sure that the two diagnoses will not conflict. In
some cases, this may involve contacting the CHP pathologist and jointly reviewing the case.
Policy for Assignment of Marrow Cases without Biopsies
Marrow sign-out is the responsibility of the faculty/trainee on the service when the marrow biopsy
typically would come out. However, all cases done on Friday must be pre-reviewed by those on
the service that day. In addition, all marrows, pediatric or adult, with or without flow cytometry that
do not have a biopsy and are received before noon on a Friday, must be signed out by those on
the service that week. They are not the responsibility of those on the following week. Children’s
bone marrow aspirates with biopsies for metastatic tumor evaluation received on Friday will be the
responsibility of the pathologist on service the following week, even though we are only signing out
the aspirate.
General/Special Hematology Experience
1. Meet with Dr. Contis or her designee to review plan for completion of checklist that follows.
2. Plan laboratory presentation (see instructions on Continuing Education in Clinical Chemistry
and Hematology).
3. See checklist for specific activities and educational resources.
General/Special Hematology Laboratory Experience Checklist
This checklist indicates the areas that need to be covered during the general/special laboratory
experience and the specific activities that are to be performed. This should occupy approximately half
your time when combined with pediatric hematopathology (as in core resident/fellow rotation).
Check boxes to the left of specific activities when the indicated activities are completed
This checklist is also included separately and must be signed by the resident/fellow and turned in to
Dr. Swerdlow’s office at the completion of the rotation.
1.
General Activities
 Review a spectrum of abnormal peripheral blood and body fluid results. These should include:
o
Macrocytic and microcytic anemias
o
RBC changes in autoimmune hemolytic anemia
o
Thrombocytopenia and inherited platelet disorders
o
Granulocytosis and granulocytopenia
o
Lymphocytosis
o
Blasts in the peripheral blood or cerebrospinal fluid
o
Abnormal cytoplasmic inclusions in WBC & RBC as available, either as review specimens or in
the study sets
o
Metastatic tumor
o
Infectious disease: malaria, babesiosis, anaplasmosis
If cases of each of the above are not available and you are in your last week, be sure to review
teaching slides or other resources (ask Dr. Contis or designee for help if required). At the end of the
3-week rotation, meet with Dr. Contis to go over your list.
 Follow up on patients whose abnormal peripheral bloods and body fluids you have reviewed to
determine the significance of the abnormality on diagnostic and therapeutic decision making and
ultimate clinical outcome.
 Keep a list of the following (include relevant clinical information that you have obtained for each
patient):
 The laboratory tests (routine and special) that you have observed (or reviewed following
returns by the reference laboratories).
 The abnormal peripheral blood films and body fluid smears that you have seen. Also see
section 2B below.
 Plan laboratory hematology presentation for Continuing Education in Hematology (see detailed
instructions in Resident/Fellow Handbook) with a mutually agreed upon time and date at the
Clinical Lab Building (CLB) or at Shadyside (SHY).
2. Specific Activities
General Hematology Laboratory (ATL)
The laboratory supervisor, Katie Mulvey, and the hematology lead technologists, Mary Vernetti or
Chris Morain will help you with hematology instrumentation and identification of abnormal cases that
need to be reviewed. Obtain a password from Ms. Abbie Mallon, to access MediaLab.
A. General
 Review procedure manuals in General Hematology, Coagulation and Urinalysis
including the procedures for operating the Iris iQ 200 urinalysis instrument. The
purpose of this review is to learn how a procedure manual is constructed, to
appreciate the CLSI format and to learn how to find a procedure when needed.
The manuals are available in print and online in MediaLab.
 Be sure that the Laboratory Hematology Staff Meeting fellow attendance sheet is
completed with your signature at all the staff meetings/laboratory management
meetings that you attend.
 Participate in troubleshooting. This includes analysis of problems with function of
instruments, quality control, or patient data that appear spurious. The problems will
be brought to your attention by the technical staff and/or Dr. Contis or designee.
B. Hematologic Microscopy
 Review normal PB morphology, understanding variations between adult and pediatric
values. (Review ASCP sets located in room G315, if not previously reviewed or if further
review is needed).

See criteria for evaluating red cells on sheet “Red Cell Morphology Classification
(1+, 2+, 3+)” in the hard copy supplement.
 Evaluate all abnormal slides referred to the pathologist (ongoing throughout rotation). This
is performed by checking the designated hself in the Pediatric Bone Marrow sign out room
(G306) to see if there are slides for review (bone marrow technologists will usually bring
them to you). When slides are designated, the trainee should obtain clinical information
about the patient, including checking Copath for prior pathologic evaluations, then review
the slide including performing a 100-200 cell differential for peripheral blood films and a
morphologic review of the cytospin slide for a fluid. The trainee should then formulate a
differential diagnosis and then review the case with the pathologist on the laboratory
service (see schedule). This review is an essential part of the laboratory’s function since
the ATL lab is often the first place where an abnormality is detected.
 Peripheral Blood Films
 Body Fluid Cytospin slides
 Keep a list of peripheral blood/body fluid slides that you reviewed and pertinent information
 Correlate body fluid results from cytology laboratory with hematology findings.
 Alert Dr. Miroslav Djokic to interesting peripheral blood films or body fluid slides. Provide
her the slides, a photocopy of the lab values and clinical information.
C. Automated Equipment: Coulter DxH800 & LH750, Cellavision
 Review information provided in your folder
 Review procedure manual
Observe:
 Setup/Cleaning of instrument
 QC/QA Procedures, graphing
 Operation of Coulter and Cellavision
 Understand principles of instrument. This is discussed in procedure manual and also lead
techs can answer questions.
 Review interpretation of Coulter dot plots and causes of spurious results. Use procedure
manual as well as cases you observe in the laboratory.

See examples on the “Complete Blood Count” in the hard copy supplement.

See 2 slides explaining histograms and dot plots.

See up-to-date, “Automated Hematology Instrumentation”.

Learn to evaluate normal and abnormal patterns.

Understand meaning of individual flags and mechanisms for evaluating flags.

Know what a flag is.

Review CAP checklists & Instrumentation QC/QA data.
Urinalysis
1.
Sysmex UF-1000i:
 Review information provided in your folder
 Observe set-up and urinalysis runs on the analyzer
Observe:
 Set up, preparation of reagents, samples
 Running, evaluation of samples
 Review urine sediment images in Iris iQ200 and know about major urine microscopy
findings and their significance.
 Understand principles of instrument and manual back-up procedures (when and how)
 Understand sensitivities and specificity of color reactions and drug interference.
Understand principles of instrument and back-up procedures (when and how).
 Review Educational Resources
 Crystals and casts
 RBC, WBC, squamous epithelial cells
 Bacteria, yeast
2.
Coagulation automated equipment: STA-R Evolution (Diagnostica Stago, Inc)
Observe:
 Set up, preparation of reagents, samples
 Running, evaluation of samples
 Understand significance of results for pre-operative screening and monitoring
anticoagulant therapy by reading text materials or original literature and by discussion
of issues with the pathologist on the laboratory service. This should include
understanding the significance and use of the INR and anti-Xa assay.
 Observe the D-dimer procedure and understand its clinical usage as a negative
predictor for DVTs and as a positive indicator of DIC.
Administrative Aspects of Laboratory
Attend the biweekly Hematology Laboratory meeting during your 3-week rotation.
 When: Every other Wednesday at 10:30 AM, 6th Floor, CLB (Dr. Contis updates the
meeting schedule and sends out agenda).
 Where: 6th Floor, CLB
 If the resident’s rotation includes the last week of the month, they can attend the
Shadyside Laboratory Operation meeting at 8:30 AM, at Shadyside Hospital, the last
Tuesday of each month. Contact Dr. Contis for information and location.
3. Special Hematology Laboratory
Many tests are sent out to reference laboratories.
A. General
 Review test menu and procedure manual

Observe any test procedures being performed.
B. Specific Tests:

Hemoglobin Evaluation
 Understand co-migration of hemoglobins and methods for distinguishing them, clinical
significance, relationship to Sickledex.
 Understand mechanisms of false positives/negatives, effect of transfusion on findings.
 Review HPLC Examples for Variant Hemoglobins, shelved in G315 under Hematology
References.
 Review Color Atlas of Hemoglobin Disorders: A compendium based on Proficiency Testing
(located in G315).
 Understand principles of HPLC for hemoglobin separation.
 Review and interpret tracings that come back from the reference laboratories and from
CHP Laboratories.
 Review chromogram information for hemoglobinopathy information (in supplemental
materials)
 Contact Dr. Steven Dobrowolski at CHP to arrange a time for review of HPLC and followup study results. Residents are expected to meet with Dr. Dobrowolski twice at CHP.

Test of RBC function
Know how these tests are performed and how they are useful:
 RBC enzymes (G6PD, PK, GPI, etc.)
 Teaching case /recent send out file
 Read about
 Plasma, serum, urine, hemoglobin
 Read about
 Osmotic fragility
 Read about
 Heinz bodies
 Read about

Miscellaneous Tests
 Acetylcholinesterase (ACHE)
 Muramidase
 Urine, serum myoglobin
 Flow cytometry for PNH (If not reviewed in Flow rotation)
 Neutrophil oxidative product formation analysis (If not reviewed in Flow rotation.)

Staining of bone marrow smears
 Routine Stains
 Cytochemical and immunocytochemical methods/procedures

Other Hematology Testing: (Vitamin B12, serum and RBC folate, serum iron
and ferritin)
These tests are now done in chemistry.
 Review how they are used in the workup of hematologic disorders with Dr. Contis.
 Review methodology utilized (see Chemistry lead tech).
References:
 Color Atlas of Hemoglobin Disorders, A Compendium Based on Proficiency
Testing. James D. Hoyer and Steven H. Kroft, Editors, 2003.
 McPherson RA, Pincus MR (Eds.) Henry’s Clinical Diagnosis and Management by
Laboratory Methods, 21st Edition 2007.
 Haemoglobinopathy Diagnosis, 2nd edition. Barbara Bain, Blackwell Science, 2006.
Before completing your rotation, please review the completed checklist with Dr.
Contis, sign and turn into Dr. Swerdlow’s office.
I have completed the General Hematology Laboratory Checklist and reviewed it with
Dr. Contis
Resident/Fellow Name (Printed)
Signature ___________________________________
___________________________________________
Signature of Lydia Contis, MD or designee
Date ___________________
HEMOGLOBIN ANALYSIS CASE LOG
ACCESSION NUMBER
DIAGNOSIS
PB AND FLUID REVIEW LOG
ACCESSION NUMBER
DIAGNOSIS
PB AND FLUID REVIEW LOG
ACCESSION NUMBER
DIAGNOSIS
Continuing Education in Clinical Chemistry and Hematology
Description:
The Continuing Education Conference is organized around a case discussion (resident) and
scientific issue or laboratory management/quality assurance presentation (faculty). A method or
technical issue may also be presented by a lead technologist. Coordination between the 2-3
presenters is encouraged. The sessions are targeted toward technologist education. Discussion
between pathologists/trainees and technologists is encouraged. Periodic updating of important
basic concepts is welcome. Please seek input from Dr. Contis, or another hematopathologist when
planning your hematology presentation.
Day, time and location:
Determined accourding to ta mutually agreed upon time with technologists and resident. This is
facilitated by Dr. Contis. The location is usually CLB Room 1021.
Frequency of presentation: Each resident on the laboratory hematology rotation will present
once, usually on the last week of their rotation.
Length of each presentation: 15-20 minutes
Examples of Topics:
1. Case discussion (Resident or fellow).
a. “Atypical lymphocytes,” 9/4/07, Dr. A. Henry
b. “Case of G6PD deficiency,” 9/25/07, Dr. I Batal
c. “Identification of urinary crystals,” 10/16/07, Dr. M. Rollins-Raval
d. “Nucleated Red Blood Cells and the Coulter LH 750 and the Sysmex XE 2100,”
12/16/08, Dr. Hannah Kastenbaum
e. "Scaling the Peaks: High-Performance Liquid Chromatography And the Detection of
Hemoglobin S", 5/5/09, Dr. Milon Amin
f. “Cystine crystals,” 12/12/10, Dr. Kelley Garner
g. “Cryoglobulinemia and Cold Agglutinin Disease: Blood Smear and Other Findings,”
02/09/2016, Dr. Dinesh Pradhan
2. Method or technical issue (Lead technologist or other)
a. “Validation of reference ranges for automated ESR method.” 9/4/07, E. Austin
b. “Review and tips for making thick smears for blood parasites,” P. Nowack
c. “Review of PFA-100,” 9/9/08, Dr. S. Monaghan
d. “Review of Bronchoalveolar Lavage (BAL) Analysis for Cell Counts & Differentials,
12/2/08,” Dr. S. Gibson
e. “A Proposed Plan for the Comparison Evaluation of the Coulter DxH 800, Sysmex
XE, and Coulter LH 750,” Dr. S. Monaghan
3. Scientific issue, quality assurance or management (Faculty)
a. Discuss a method, disease, recent literature, QA study, etc.
b. “Immature reticulocyte fraction,” 10/21/08,” Dr. L. Contis
c. “Automated Cell Counts on Pleural Fluid: Review of a Study on the Sysmex XE2100, 12/2/08,” Dr. R. Felgar.
d. “Platelet Counting by the Coulter LH 750 and Sysmex XE 2100,” 12/16/08, Dr. S.
Monaghan
Pediatric Hematopathology Checklist
Note: Items indicated in BOLD constitute the basic knowledge expected of residents
rotating in Hematopathology. Additional (non-bolded) items should also be included for
advanced learners including fellows.
 Orientation with Hematopathologist on Pediatric Hematopathology service.
 Knows how normal pediatric blood and bone marrow differ from those of adults.
 Knows special aspects of neonatal hematopathology (see K. Foucar, “Neonatal
Hematopathology: Special Considerations” in Collins RD and Swerdlow SH, eds. Pediatric
Hematopathology and Maria Proytcheva Diagnostic pediatric hematopathology).
 Knows role of cytogenetic and molecular diagnostic studies in evaluating hematopoietic /
lymphoid disorders in bone marrow and blood.
 Learn diagnostic criteria using multiparameter approach and clinical implications for each of
the following:
Diagnosis / Finding
Observed
Actual Case
Observed
Teaching
File Case
Read About
NEOPLASTIC DISORDERS
Acute Lymphoblastic Leukemia
B-lymphoblastic leukemia / lymphoma
B-lymphoblastic leukemia/lymphoma with recurrent
cytogenetic abnormalities (See WHO book for
specific categories)
T- lymphoblastic leukemia / lymphoma
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Acute Myeloid Leukemias
Acute Myeloid Leukemia with 11q23 abnormality
Acute Myeloid Leukemia with recurrent
cytogenetic abnormality, other
Acute Megakaryoblastic Leukemia
AML/MDS associated with congenital marrow
failure syndromes
Acute Myeloid Leukemia, not otherwise
specified
Mixed lineage acute leukemia
Myeloid proliferations associated with Down
Syndrome
Acute Myeloid Leukemia
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Transient Abnormal Myelopoiesis
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Juvenile Myelomonocytic Leukemia
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Myelodysplastic Syndromes
Childhood Myelodysplastic Syndromes
Refractory cytopenia of childhood
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Burkitt Lymphoma
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Diffuse Large B-cell Lymphoma
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Anaplastic Large Cell Lymphoma, ALK+
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Pediatric Nodal Marginal Zone Lymphoma
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Pediatric Follicular Lymphoma
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Systemic EBV+ T-cell LPD of Childhood
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Hydroa Vacciniforme-like Lymphoma
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Neuroblastoma
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Rhabdomyosarcoma
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Chronic Myeloproliferative Neoplasms
Chronic Myelogenous Leukemia
Myelodysplastic/Myeloproliferative Disease
Mature Lymphoid Neoplasms
Nodular Lymphocyte Predominant Hodgkin
Lymphoma
Classical Hodgkin Lymphoma
Histiocytic Neoplasms
Langerhans cell histiocytosis
Mast Cell Disease
Metastatic Tumors
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Fanconi Anemia
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Diamond Blackfan Syndrome
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Congenital Dyserythropoietic Anemia
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Congenital Sideroblastic Anemia
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Pearson Syndrome
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Cyclic Neutropenia
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Shwachman-Diamond Syndrome
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Dyskeratosis Congenita
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Reticular Dysgenesis
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May-Hegglin Anomaly
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Bernard-Soulier Syndrome
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Wiskott-Aldrich Syndrome
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Congenital Amegakaryocytic Thrombocytopenia
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Ewing sarcoma
NON-NEOPLASTIC DISORDERS
Congenital Disorders/Syndromes with Prominent
Hematologic Abnormalities (Hereditary bone
marrow failure)
Severe Congenital Neutropenia/Kostmann’s
Syndrome
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X-linked thrombocytopenia
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Thrombocytopenia with Absent Radii (TAR)
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Gray Platelet Syndrome
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X-Linked Lymphoproliferative Disorder
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DiGeorge Syndrome
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Severe Combined Immunodeficiency Disease
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Red Cell enzyme deficiencies-hemolytic anemia
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Hemoglobinopathies
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Sickle cell disease
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Thalassemia
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Other
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Gaucher Disease
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Niemann-Pick
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Mucopolysaccharidoses
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Transient erythroblastopenia of childhood
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Alloimmune hemolytic anemia of newborn
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Iron deficiency
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B12/folate deficiency
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Parvovirus
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Autoimmune Thrombocytopenic Purpura
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TTP/Hemolytic Uremic Syndrome
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Congenital syndromes
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Familial Platelet Syndrome with Predisposition to
Red Cell cytoskeletal/membrane abnormalitieshemolytic anemia
Other Anemias and Conditions
Thrombocytopenia (see also above)
Drugs/toxins
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Infection-associated
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Eosinophilia
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Basophilia



Lymphopenia



Infection



Medication



Autoimmune



Nutritional Deficiency



Congenital Disorders



Epstein Barr Virus (infectious mononucleosis)



Pertussis



Infection, other



Granulomas



Myelofibrosis



Thrombocytosis
Neutropenia
Immune neutropenia
Neutrophilia/Leukemoid Reaction
Infection/inflammatory disorders
Medications
Lymphocytosis



Idiopathic Drugs



Secondary



Infection Associated



Drugs/toxins


















Aplastic Anemia
Hemophagocytic/Lymphohistocytic Syndromes
Familial lymphohistiocytosis
Secondary hemophagocytic/macrophage
activation syndrome
Immunodeficiencies
Autoimmune Lymphoproliferative Syndrome
Other Primary Immunodeficiencies (see
above)
PRESENTED THE FOLLOWING PEDIATRIC BONE MARROW OR LYMPH NODE CASES
(Fellows should submit presentation in portfolio)
PHB NUMBER
DIAGNOSIS
UTILIZED THE FOLLOWING BONE MARROW RESOURCES
 Swerdlow SH, Collins RD Pediatric Hematopathology, Churchill Livingstone, 2001.
 Orkin, SH, et al., Nathan and Oski’s Hematology of Infancy and Childhood, 7th Edition.
 Penchansky L, Pediatric Bone Marrow, Springer, 2004.
 Proytcheva, Maria A. Diagnostic pediatric hematopathology. Cambridge: Cambridge
University Press; 2011.
NOTE: Reading is an important component of this rotation. It is recognized that not all of the
above resources can be used nor can most be read in entirety. Use of electronic and other
resources to find and read up-to-date journal articles is also critical.
I have completed the Pediatric Hematopathology Checklist
Name __________________________________________ (printed)
__________________________________________ (signature)
Date
__________________________________________
UPMC PRESBYTERIAN SHADYSIDE
Automated Testing Laboratory
Pathologist Review Form
Patient Name /Medical Record #
Hospital: PUH/CLB
SHY
CHP
MWH
Date:
Patient Diagnosis:
Specimen Type:
Peripheral blood smear
Pleural fluid
Peritoneal fluid
CSF
Other
Tech Name/ Tech comments:
PATHOLOGIST COMMENTS:
BLID=Blasts are identified
FCSR=Flow cytometry studies recommended
AUERP=Auer rods present
CBCLDF=Atypical lymphoid population,
worrisome for lymphoproliferative disorder.
Recommend flow cytometric evaluation if clinically
indicated
GTPLC=Plasma cells identified, correlation with
flow cytometry studies recommended
RMCP=Reactive mesothelial cells present
GTCBM=Correlation with pending bone
marrow evaluation recommended
INCP=Inflammatory cells present
GTAMC=Clusters of atypical mononuclear cells,
worrisome for malignancy, correlation with
cytology recommended
BACIE= Intracellular and extracellular bacteria
present
Additional Pathologist comments:
Correct the Differential? Yes / No
Pathologist comment to tech:
RESIDENT/FELLOW :
PATHOLOGIST :
Stain quality: Satisfactory / Unsatisfactory
Children’s Hospital of Pittsburgh of UPMC
AUTOMATED TESTING LABORATORY
412-692-9836
PATHOLOGIST REVIEW
HEMATOPATHOLOGY DEPARTMENT
Name/Medical Record #:
Date/Accession #:
Patient Diagnosis
Peripheral Blood Smear: Yes / NO
Fluid type: CSF, Synovial, Pleural, Peritoneal, Pericardial, Bronchial Lavage
TECHNOLOGIST COMMENT:
TECH SUBMITTING REVIEW:
PATHOLOGIST COMMENT: To be entered into Sunquest
SEE CORRECTED DIFF 

PATHOLOGIST COMMENT: For Technologist only
REVIEW RESIDENT/FELLOW:
REVIEW PATHOLOGIST:
Clinical Experience in
Hematology
Clinical Experience in Hematology at UPMC Shadyside
Clinical Hematology / Performance of Bone Marrow Experience
nd
All activities are based at Hillman Cancer Center, 2 Floor unless indicated otherwise. Upon arrival, contact
the on site bone marrow technologist who can help orient you to the facility and facilitate your opportunity to
learn how to perform bone marrow examinations. The bone marrow technologist can either be found in room
A220.36 or paged at (412) 958-8812 or the in-house pager 11443. This can also be facilitated by your seeing
Celina Fortunato, in G325 or one of the bone marrow technologists who can call over to UPMC-Shadyside
the week before you go over there.
MONDAY
AM
PM

Dr. Redner
Clinic (Hillman
Cancer Center,
nd
2 Floor
Conference Rm.
One).
YOU ARE
RESPONSIBLE
FOR CONTACTING
DR. REDNER ONE
WEEK PRIOR TO
YOUR VISIT TO HIS
CLINIC VIA EMAIL
TO CONFIRM HE
HAS CLINIC
 After Dr.
Redner’s clinic is
done, go with
Bone Marrow
Technologists
on all marrows.
TUESDAY
 Learn to perform
bone marrow
aspirates /biopsies
with Physician’s
Assistant
 Go with Bone
Marrow Technologist
on all marrows if
Physician’s Assistant
is not available
 Dr. R. Smith Clinic,
Area A, Pod 1


Dr. Lim/Dr. Agha’s
th
Clinic, 4 Floor,
Hillman Cancer
Center,
Learn to perform
bone marrow
aspirates /biopsies
with Physician’s
Assistant
FRIDAY
WEDNESDAY

Dr. Kiss/Dr.
Bontempo’s
Hematology
Clinic, Area A,
Pod 3, Rooms
3B,C,D (every
other Friday)
 Begin UPMCPresbyterian based
flow cytometry
laboratory rotation.
Report to:
Clinical Laboratory
Building
th
9 Floor, Room 9033
3477 Euler Way
Pittsburgh, PA 15213
412-864-6180
Objectives:



Learn how clinical hematology is practiced including patient concerns and what clinicians need from
pathologists.
Know how to perform bone marrow biopsies and aspirates including actually performing preferably at
least 2 procedures.
Know how bone marrow specimens are processed.
Performance of Bone Marrow
Aspirations & Biopsies
Performance of bone marrow aspirations and biopsies (with hematology/oncology
division)
Trainees are expected to learn how to perform bone marrow aspirations and biopsies. They
should aim to observe and then perform a total of about ten marrows. It is recognized that
this goal may not be met. Some of this must be done while the trainee is on their UPMCP/Hillman Cancer Center Hematology rotation. The remainder should be done later in their
training (See below).
A.
The trainee will be able to observe and perform marrows as part of the clinical
experience in hematology (see “Clinical Experience in Hematology”).
B.
The trainee is required to keep a record of each marrow observed and performed
including the name of the patient, bone marrow number and diagnosis. For the bone
marrows actually preformed, the person supervising the procedure needs to
sign off on the form. In addition, the aspirate smear and biopsy obtained must
be reviewed by a faculty member to assess and document their adequacy. The
form should be completed at the end of the rotation and given to Dr. Swerdlow’s
coordinator in room PUH G333. There is also a hard copy of this form in the red
packet.
C.
The trainee should also try to observe several pediatric marrows during the
pediatric/laboratory hematology section of the rotation. These should also be
recorded on the log when noting which are pediatric cases or use a separate sheet
and check off pediatric at the top.
Residents have the opportunity to perform bone marrow aspirates and biopsies at the VA hospital
later in their training.
HEMATOPATHOLOGY ROTATION PERFORMANCE OF MARROW BIOPSIES AND ASPIRATES FORM
Satisfactory completion of the rotation REQUIRES the return of this form.
Name:
Rotation Dates:
AGE OF PATIENTS:
ADULT
BIOPSIES / ASPIRATES PERFORMED
PEDIATRIC
TO BE COMPLETED BY RESIDENT/FELLOW
Patient Name
(REQUIRED)
PHB Number
(REQUIRED)
Aspirate
TO BE COMPLETED BY CLINICAL SUPERVISOR
Biopsy
Satisfactory
Signature
Problem
TO BE COMPLETED BY
HEMATOPATHOLOGIST
INITIALS
Aspirate
S
U
NA
Biopsy
S
U
NA
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
(Please use back of form if needed.)
S = SATISFACTORY
U = UNSATISFACTORY (PUT COMMENT) NA = NOT
APPLICABLE
BIOPSIES / ASPIRATES OBSERVED
Patient Name
PHB Number
(REQUIRED)
Aspirate
Biopsy
(REQUIRED)
1.
2.
3.
4.
5.
6.
Patient Name
PHB Number
(REQUIRED)
(REQUIRED)
Aspirate
7.
8.
9.
10.
11.
12.
Please get recut H& E and aspirate smear stained. Have attending hematopathologist review and evaluate in section above.
TRAINEE SIGNATURE
DATE
DIRECTOR (OR DESIGNATE) SIGNATURE
DATE
PLEASE RETURN COMPLETED FORM PRIOR TO END OF ROTATION TO DR. SWERDLOW’S COODINATOR, RM G333.
Biopsy
Flow Cytometry Laboratory
Experience
Flow Cytometry Laboratory Experience
Introduction to flow cytometry
Understanding of flow cytometric immunophenotypic techniques and interpretation of
the resultant data is an integral part of all the bone marrow and lymph node
rotations. In addition, however there is a brief concentrated exposure to the flow
cytometry laboratory including the technical aspects of flow cytometry and the basic
operation of a flow cytometry laboratory. In most cases this will occur following the
core pediatric bone marrow rotation (week 4). This is also the opportunity to learn
about flow cytometric DNA content study.
1. Meet with the Flow Cytometry Lab lead technologist or designate for orientation.
2. Become familiar with instrumentation and procedures in laboratory under the guidance
of the lead technologist.
 Immunostaining.
 Acquisition and analysis using flow cytometry.
 Quality control/quality assurance.
 Operation of a large clinical flow cytometry laboratory
3. Complete checklist.
4. Educational materials available:
 Flow Cytometry First Principles. Alice L. Givan.
 Flow Cytometry in Clinical Diagnosis. 4rd edition, editors: D. Keren, J.P.
McCoy and J.L. Carey.
 Flow cytometric immunophenotyping for hematologic neoplasms. Blood
111(8)3941-3967, 2008.
Flow Cytometry Rotation Checklist
Note: Items indicated in BOLD constitute the basic knowledge expected of residents rotating in
Hematopathology. Additional (non-bolded) items should also be included for advanced learners
including fellows.

Orientation with the Lead Technologist or her designate.

Understand the principles of flow cytometric immunophenotyping.

Gain familiarity with instrument set –up, compensation and quality
control.

Gain familiarity with procedures for surface and cytoplasmic antibody
staining.

Understand the principles of analysis.

Perform additional data analysis using DIVA software on specimens
previously analyzed in the clinical Flow Cytometry Laboratory
Know the immunophenotypic characteristics of the following entities:
Diagnosis/Finding
Observed
Actual
Case
Observed
Teaching
File Case
Read
About
Normal bone marrow



Hematogones



Reactive Lymph Node



Follicular lymphoma



Chronic lymphocytic leukemia/Small lymphocytic
lymphoma



Mantle Cell lymphoma



MALT lymphoma



Lymphoma
Diagnosis/Finding
Burkitt lymphoma
Observed
Actual
Case

Observed
Teaching
File Case

Read
About




Hairy Cell Leukemia



B-Cell Prolymphocytic Leukemia



T-Cell Prolymphocytic Leukemia



Sézary Syndrome



T-cell and NK cell Large Granular
Lymphoproliferative Disorders



Adult T-cell Leukemia / Lymphoma



Acute Promyelocytic Leukemia with t(15;17) (q22;q12)
PML-RARA



Acute Myeloid Leukemia associated with t(8;21)



Acute Myeloid Leukemia associated with inv(16)



Acute Myeloid Leukemia with monocytic differentiation



Acute Megakaryocytic Leukemia



B-Lymphoblastic leukemia/lymphoma



T-lymphoblastic leukemia/lymphoma



Minimal Residual disease in Acute Lymphoblastic Leukemia






Neutrophil Oxidative Burst Analysis



DiGeorge syndrome evaluation



Leukocyte adhesion molecule deficiency



T-cell lymphoma
Chronic leukemia
Acute Lymphoblastic Leukemia
Paroxysmal Nocturnal Hemoglobinuria
Chronic Granulomatous Disease
UTILIZED THE FOLLOWING FLOW CYTOMETRY RESOURCES
 McPherson, R.A., Pincus, MR., Henry’s Clinical Diagnosis and Management by
Laboratory Methods 21st edition, 2007. Chapter 33- The Flow Cytometric Evaluation of
Hematopoietic Neoplasia, Wood and Borowitz, pg 599.
 Givan, A.L., Flow Cytometry, First Principles, 2nd Edition, 2001.
 Keren, D.F., McCoy, J.P., and Carey, J.L., Flow Cytometry in Clinical Diagnosis, 3rd
Edition, 2001.
 Craig, F.E., Foon, K.A., “Flow cytometric immunophenotyping for hematologic
neoplasms.” Blood 111. 8 (2008): 3941-3967.
I have completed the Flow Cytometry Checklist
Name
(printed)
(signature)
Date
Test Menu of Routine Flow Cytometry Panels
Acute:
CD16&57/CD7/CD4/CD3/CD56/CD8/CD2/CD45
CD36/CD123/CD64/CD33/CD34/CD14/HLA-DR/CD45
CD15/CD56/CD117/CD13/CD11b/CD16/HLA-DR/CD45
CD7/CD13&33/CD19/CD56
Kappa/Lambda/CD5/CD19/CD10/CD38/CD20/CD45
cytoplasmic TdT/MPO/CD3/CD34
**Pediatric specimens also include the CD58/CD123/CD34/CD19/CD10/CD38/CD20/CD45
Basic Screen: Limited evaluation of lymphoid and myeloid cells to be used when the following criteria are met: no
significant history, no cytopenias, and no morphologic abnormality e.g. staging for Hodgkin lymphoma. Also, to
follow-up documented CML, or rule-out a myeloproliferative disorder such as CML, polycythemia vera (PV),
essential thrombocythemia (ET), or idiopathic myelofibrosis.
CD14/CD13&33/CD45/CD34
CLL PB/BM:
CD14/CD13&33/CD45/CD34
CD23/CD49d/CD5/CD19/CD38//FMC7/CD200
CLL LN:
CD23/CD49d/CD5/CD19/CD38/-/FMC7/CD200
Mini CLL Follow-Up (PB or BM): Limited evaluation of chronic lymphocytic leukemia (CLL) or small
lymphocytic leukemia (SLL) with previous diagnosis at UPMC including flow cytometric evaluation. PB or BM
submitted for evaluation of CLL, and morphology review is consistent with that diagnosis and does NOT
demonstrate another disease process e.g. increased blasts.
CD14/CD13&33/CD45/CD34
CD23/CD49d/CD5/CD19/CD38/-/FMC7/CD200
DiGeorge:
CD45RA/CD62L/CD3/CD4
Lymph PB/BM:
CD14/CD13&33/CD45/CD34
Lymph LN:
**Pediatric specimens also include the cytoplasmic TdT/MPO/CD3/CD34
MDS:
CD7/CD13&33/CD19/CD56
Mini AML: Previous diagnosis of acute myeloid leukemia (AML) established at UPMC including flow
cytometric evaluation (NOT flow only). PB or BM submitted for evaluation. Review previous
phenotype and add additional aberrant markers when appropriate.
Mini B-ALL: Previous diagnosis of B-lineage acute lymphoblastic leukemia (ALL) established at
UPMC including flow cytometric evaluation (NOT flow only). PB or BM submitted for evaluation of
ALL. Review previous phenotype, and add additional aberrant markers when appropriate.
CD14/CD13&33/CD45/CD34
CD58/CD123/CD34/CD19/CD10/CD38/CD20/CD45 (30,000 events)
cytoplasmic TdT/MPO/CD3/CD34
**If MRD evaluation is also requested at the same time, the CD58 tube will be
done in a separate flow procedure (FC2).
B-ALL MRD:
CD58/CD123/CD34/CD19/CD10/CD38/CD20/CD45 (maximum # of events collected)
Mini B-cell Lymphoma Follow-up (PB or BM): Limited evaluation for follow-up B-cell lymphoma
with previous diagnosis at UPMC including flow cytometric evaluation (NOT flow only). PB or BM
submitted for evaluation of lymphoma, and morphology review consistent with that diagnosis and does
NOT demonstrate another disease process e.g. increased blasts.
CD14/CD13&33/CD45/CD34
**bcl-2 testing should be performed on all cases with a history of follicular lymphoma. or
if the requisition asks for testing for bcl-2, bcl-2 gene rearrangement, or t(14:18) testing
(even fi this is indicated in the molecular or cytogenetic area of the requisition.
Mini T-ALL: Previous diagnosis of T-lineage acute lymphoblastic leukemia (ALL) established at
UPMC including flow cytometric evaluation (NOT flow only). PB or BM submitted for evaluation of
ALL. Review previous phenotype, and add additional aberrant markers when appropriate.
CD14/CD13&33/CD45/CD34
CD7/CD13&33/CD5/CD56
Myeloma:
Kappa/Lambda/CD5/CD19/CD10/CD38/CD20/
CD45 cytoplasmic TdT/MPO/CD3/CD34
CD14/CD13&33/CD45/CD34
CD3/CD138/CD19/CD56
cytoplasmic Lambda/CD138/CD19/Kappa
NOBA:
Blank
Resting (DHR only)
Stimulated 10
Stimulated 15
Stimulated 25
**Both a patient and a control are stained for this assay.
PNH:
RBCs: CD235a/CD59
WBCs: Flaer/CD16/CD33/CD15/CD14/-/CD45
**Both a patient and a control are stained for this assay.
8-Color CSF
Tube:
Kappa/Lambda/CD5/CD13&33/CD34/CD14/CD19/CD45
8-Color B-cell
Tube:
Kappa/Lambda/CD5/CD19/CD10/CD14 or CD38/CD20/CD45
The following page includes all of the validated extra tubes that can be ordered in the Flow Cytometry
Laboratory.
VALIDATED EXTRA TUBES
FITC
CD2
CD2
CD2
CD7
CD7
CD16&57
CD16&57
CD16&57
CD23
CD52*
CD61
CD103
CD123
CD158a
Bcl‐2
Bcl‐2
BLK Kappa
BLK Kappa
FMC‐7
Lambda
Lambda
TCR a/b
TCR a/b
TdT
PE
CD7
CD8
CD30
CD26
CD1a
CD7
CD7
NKG2A
CD49d
PerCP
‐Cy5.5
CD117
CD3
CD3
CD3
PE‐
Cy7
APC‐
H7
V450
V500
Short name
Mast Cell
CD25
CD4
CD30
CD19
CD3
CD3
CD4
CD94
CD5
APC
CD3
CD3
CD19
CD4
CD5
CD56
CD56
SEZ
CD45
CD8
CD8
CD38
CD5
CD56
FMC‐7
CD45
CD45
CD200
PB/BM T W/5
KIR (2 OF 2)
49d
CAMPATH
CD13&33
CD11c
LAIR
CD158e
CD10
CD10
BLK Lambda
BLK Lambda
CD23
Kappa
Kappa
TCR g/d
TCR g/d
CD22
CD41a
CD20
11c
CD16
CD20
CD19
CD19
CD20
CD19
CD19
CD20
CD3
CD3
CD79a
CD25
CD3
CD34
CD25
CD103
CD158b1
MEGAKARYOCYTE
CD3
CD8
CD20
CD56
CD45
CD45
HAIRY
KIR (1 OF 2)
CD5
CD10
CD5
CD5
CD10
CD25
CD4
FMC7
CD8
CD34
CD45
CD45
ALPS
CYTO B‐CELL
*CD52 FITC for consideration for CAMPATH therapy put in combination with previously tested
antibodies
ANTIBODIES AVAILABLE IN THE FLOW CYTOMETRY LABORATORY
ANTIBODY
CD1a
CD2
CD3
CD4
CD5
CD7
CD8
CD10
CD11b
CD11c
CD13
CD14
CD15
CD16
CD19
CD20
CD22
CD23
CD24
CD25
CD26
CD30
CD33
CD34
CD36
CD38
CD41a
CD43
CD45
CD45RA
CD45RO
CD49d
CD52
CD56
CD57
CD58
CD59
CD61
CD62L
CD64
CD79a
CD79b
CD81
CD94
FITC
PE
PerCP
PerCP‐
Cy5.5
PE‐Cy7
X
X
X
X
APC
APC‐H7
Alexa Fluor
X
X
750
V450
V500
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X (C)
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
CD103
CD117
CD123
CD138
CD158a
CD158b1
CD158e
CD200
BCL‐2
Flaer
FMC‐7
GLYCO A
(CD235a)
HLA‐DR
Kappa
Lambda
LAIR
MPO
NKG2A
TCR a/b
TCR g/d
TdT
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Guidelines for Flow Cytometry Staining Decisions
1. Pathologists Decisions. The pathologist who is assigned to the appropriate service
should be called for a decision in any of the following circumstances:
a. Limited specimen. Either there are too few cells to set-up the indicated panel or the
appropriate panel would use the specimen in its entirety. For some limited CSF
specimens, technologists can make a decision if there is a previous history, with flow
cytometry run in our system, of CD10 positive precursor-B acute lymphoblastic
leukemia, CD34 positive acute myeloid leukemia, or B-cell lymphoma The
Pathologist should be called for limited CSF samples if there is history of another
malignancy. Also, if there is no history of a hematolymphoid malignancy, such as
leukemia, lymphoma, or myeloma, after review of clinical information, the 8-color
CSF tube can be run.
b. There are questions about any of the information available (including the history,
clinical information, test requested or morphologic appearance).
c. For whatever reason, there is uncertainty regarding the appropriate panel.
d. A technologist who has met the required morphology or decision competency level is
not available.
The following protocol is recommended when calling a pathologist for a decision:
a. Identify yourself and inform the pathologist that you are calling for a flow decision.
b. Notify the pathologist of the following information:
i.
ii.
Cellularity / adequacy of specimen. Alert the pathologist if the cellularity is low.
Tell them the total number of cells and / or approximately how many tubes can
be set-up.
Specimen Type (peripheral blood, bone marrow, fluid etc.).
iii. Flow-only or In-house.
iv. Test requested (evaluation of lymphocytes or blasts).
v.
Clinical Information provided.
vi. Previous pertinent diagnoses in CoPath including the phenotype.
vii. Presence and quantity of abnormal cells including blasts / immature
mononuclear cells, lymphocytes / abnormal lymphocytes, plasma cells, and
unidentifiable cells.
2. Technologist Decisions. Flow decisions can be made by a technologist who has met
the required morphology and decision competency level, in the following circumstances:
a. New Adult Acute Leukemia. A complete “Acute Leukemia Panel” can be set-up if the
smear demonstrates numerous blasts, immature cells, or monocytes. The designated
hematopathologist should be paged with a text message to alert them about a possible
new case of acute leukemia. The pathologist should be called directly if there are any
questions about the tubes that should be set-up, the urgency of the results, or the
morphologic appearance. The pathologist should also receive a text message when the
case is completed in order to review the pdfs.
b. Full panel. One of the standard complete panels can be set-up if the requisition
indicates the disease entity being evaluated, and both the previous history in CoPath,
and the morphologic review are consistent with that diagnosis. Technologists are
encouraged to be proactive in ordering any additional tubes indicated by previous flow
cytometric results or the information provided on the requisition e.g. the bcl-2 extra in
the evaluation of BM involvement by follicular lymphoma. Novel, untested,
combinations are NOT recommended unless the antibodies have already been
evaluated in their standard combinations.
c. Limited panel. One of the authorized limited panels (see the test menu list) can be
ordered if the following criteria are met:
i.
The patient is being evaluated for a disease entity for which there is a
previous diagnosis at UPMC-Presbyterian/Shadyside including flow
cytometric evaluation (NOT flow only, except for PB evaluation of CLL).
ii.
The requisition indicates follow-up of that disease entity.
iii.
The morphologic findings are consistent with that diagnosis,
or treatment of that entity, and do NOT indicate another disease
process.
d. CSF specimens. If there are only enough cells available for one tube, flow
cytometry technologists can make a decision of which tube to run, based on
the following guidelines:
i. Previous history of precursor-B acute lymphoblastic leukemia with flow cytometry
run in our system:
• CD10 positive - set up CD10 / CD13&CD33 / CD19 / CD34
• CD10 negative - call for decision
• Any questions - call for decision
ii. Previous history of acute myeloid leukemia with flow cytometry run in our system:
• CD34 positive - Set up 8-color CSF tube
• CD34 negative - call for decision
• Any questions - call for decision
iii. Previous history of B-cell lymphoma with flow cytometry or previous diagnostic
evaluation in our system:
i. set up 8-color B-cell tube
iv. No history of a hematolymphoid malignancy, such as leukemia, lymphoma,
myeloma, after review of CoPath and available clinical information:
i. set up 8-color CSF tube (K/L/CD5/CD13&33/CD34/CD14/CD19/CD45).
3.
Technologist Ordering of Extra's. After review of the results from the original panel,
technologists are encouraged to be proactive in ordering any additional tubes indicated, or
text paging the Pathologists to alert them of the possible need for Extra's. For example:
a. bcl-2 extra: abnormal CD10 positive B-cell population
b. CD23/CD49d/CD5/CD19/CD38/-/FMC7/CD200: abnormal CD5 positive B-cell
population.
c. CD123/LAIR/CD11c/CD25/CD103/CD3/CD20/CD45: abnormal CD10 negative,
CD negative B-cell population.
TEST SPECIFICATIONS: CLINICAL FLOW CYTOMETRY LABORATORY
Leukemia Panels, CLL/Lymphoma Panels, T-Lymphocyte Subset Panels, PNH, NOBA
DELIVER ALL SAMPLES DIRECTLY TO THE FLOW CYTOMETRY LABORATORY
Clinical Laboratory Building
th
Room 9032 (9 floor)
3477 Euler Way
(412) 864-6173
FLOW CYTOMETRY LAB HOURS OF OPERATION
Monday through Friday: 8:00 am to 6:00 pm. In all cases, notify the lab before the specimen is
sent (412- 864-6173). It is recommended that on Friday specimens be received by 5 pm.
Saturday: Emergency specimens can be processed on Saturday. The laboratory must be notified by 12
pm and the specimen must arrive by 1 pm. The hematopathologist on call can be reached through the
UPMC Oakland operator at (412) 647-2345.
Sundays and Holidays: The lab is closed on Sunday and the following holidays: New Year’s Day, Martin
Luther King Day, Memorial Day, July 4, Labor Day, Thanksgiving Day and Christmas Day. Specimens
should be received by 3 pm on the day before a holiday.
SPECIAL INSTRUCTIONS



Send a completed requisition. In addition FAX the requisition to 412-682-1784 in advance of
sending the specimen.
See specific instructions for storage/transport of specimens.
Use adequate safety measures in transporting specimens.
LEUKEMIA, CLL/LYMPHOMA PANELS
Test Description
These tests utilize a panel of monoclonal antibodies in the immunophenotypic analysis of hematopoietic
and lymphoid proliferation. The panels are used to assess cell lineage and to look for features that
support a neoplastic rather than reactive proliferation.
Specimen Requirements
Bone marrow aspirate: Minimum of 2 ml in a heparinized (green top) tube. Store/transport
specimen at room temperature. If possible send one non-heparinized,
unstained aspirate smear.
Peripheral blood:
One EDTA (preferred; purple top) tube or heparinized (green top) tube
with at least 5 ml of blood. Store/transport specimen at room
temperature.
Lymph nodes:
Preferably 1 cm fresh tissue in RPMI or any other growth media.
Normal saline may be used if RPMI is unavailable and transport time is
kept to a minimum. A small portion of all tissues (or other tissues) will be
processed for histologic sections. Send tissue as soon as possible –
preferably to be received within 24 hours. Store specimen at
o
2-8 C if delay in transport.
3
Body fluids:
Preferably should be a minimum of approximately 100,000 cells (e.g. 100
cells/ul x 1 ml; 10 cells/ul x 10 ml). Testing can be attempted even on
very low count specimens. Send specimen as soon as possible.
o
Store at 2-8 C if delay in transport.
Fine needle aspirates: Place cores (preferably two) and any additional aspirate in RPMI or other
growth media. Normal saline may be used if RPMI is unavailable and
transport time is kept to a minimum. Send tissue as soon as possible –
o
preferably to be received within 24 hours. Store specimen at 2-8 C
if delay in transport.
T-LYMPHOCYTE SUBSET EVALUATION
Test Description
This test may be identified as T Cell Subsets, T and B Cells, CD4:CD8 counts and other synonyms. The
test panel includes a Total T or Pan T antibody, a Total B cell or Pan B antibody, a Total Helper antibody,
a Total Suppressor antibody, the Helper/Suppressor, and a Total Natural Killer antibody. There are no
functional tests associated with these antibodies.
A limited CD4 evaluation can be performed if requested.
One 4 ml EDTA (purple top) tube or two BD microtainer (purple top) pediatric tubes. Store/transport
specimen at room temperature. Testing must performed within 48 hours of specimen collection.
EVALUATION FOR PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH)
Test Description
The flow cytometric test for PNH evaluates the GPI-linked markers: CD59 on RBCs; CD24 and CD16 on
Neutrophils and CD14 on Monocytes. The WBC assay also determines binding of the fluorochrome
labeled toxin Aerolysin.
One 4 ml EDTA (purple top) tube. Store/transport specimen at room temperature. Testing must be
performed within 48 hours of specimen collection.
EVALUATION FOR NEUTROPHIL OXIDATIVE BURST ASSAY (NOBA)
Test Description
This test is a replacement for the Nitro Blue Tetrazolium (NBT) test for Chronic Granulomatous Disease
(CGD). The neutrophil oxidative burst assay measures the respiratory burst of neutrophils following
stimulation with phorbol 12-myristate 13-acetate (PMA). Patients with CGD lack the usual oxidative burst.
One 4 ml EDTA (purple top) tube kept at room temperature. Store/transport specimen at room
temperature. Testing must be performed within 24 hours of specimen collection. In addition a normal
control (from an UNRELATED donor) MUST accompany the specimen.
CONTACTS, DIVISION OF HEMATOPATHOLOGY
Steven H. Swerdlow, M.D.
Director, Division of Hematopathology
(412) 647-5191
Wendy
Shallenberger
Ruth Bates
Supervisor, Flow Cytometry Lab
(412) 647-6518
Lead Technologist, Flow Cytometry
(412) 864-6180
Rev 8/14
ICD9 Codes for Flow
A list of ICD9 Codes commonly received in the Flow Laboratory. This list is to be used as an
aid in interpreting ICD9 codes. It is not to be used to assign ICD9 codes to a case.
IDC9
Disease
78.9 (V78.9) Blood Screen (NOS)
79.99 Viral Infection NOS
172.6 Malignant Melanoma
194.9 Malignant Endocrine Neoplasm (NOS)
201.9 Hodgkin’s Disease (NOS)
202.1 Mycosis Fungoides Unspec Site
202.4 Hairy Cell Leukemia Unspec Site
202.6 Mastocytosis
202.8 Lymphoma Unspec Site
203 Multiple Myeloma No Remission
203.01 Multiple Myeloma In Remission
204.1 CLL - No remission
205 Myeloid leukemia
205.1 CML - No remission
205.11 CML - In remission
207.8 Mast cell leukemia
208.9 Unspecified Leukemia
238.4 Polycythemia Vera
238.7 Lymphoproliferative Chronic (NOS)
238.7 Myeloproliferative Chronic (NOS)
273.3 Macroglobulinemia
284.8 Aplastic Anemia NEC
284.9 Aplastic Anemia NOS
285.6 Lymphadenopathy
285.9 Anemia (NOS)
287.4 Secondary Thrombocytopenia
288 Agranulocytosis
288.1 Function Disorder Neutrophils
288.8 White Blood Disease NEC
289.89 Myelofibrosis
709.9 Skin Disorder NOS
786.5 Chest Pain
789.2 Splenomegaly
Adult Bone Marrow
Experience
Adult Bone Marrow Experience (~4 weeks)
1. Adult Bone Marrow Sign Out
A.
Sessions with Adult Bone Marrow Technologists -- if not already done during
pediatric marrow rotation (eg AP only residents), please set up a time to review
peripheral blood and bone marrow aspirate smears with technologists during
your first week.(typically Tuesday afternoon is best)
B. Participation in sign-out with staff. Inform Hematopathologist on BM #1 Service that
you are starting the rotation and review expectations in terms of bone marrow
preview, sign-out, dictation, and proofing ( see “Trainee Responsibilities during
Bone Marrow Rotation”).The trainee should discuss with the faculty the optimal
number of cases to evaluate prior to sign-out. .The number of cases the resident
is expected to evaluate will increase progressively during the rotation.
C.
Review results of ancillary procedures performed on marrows you have reviewed
and read addenda that faculty issue (see Special Procedure Review by
Resident/Fellow in CoPath).
D.

Blood Cell Morphology. (Published by the ASCP). If not already done during
pediatric marrow rotation (ie AP only residents).. review the RBC, WBC, Normal
and Abnormals Binders with CDs in Hematopathology library (G323) or images
and PDF key are also on shared resident drive, under “CP Lecture
Material\Hemepath\ASCP Hematology Images”

A teaching set of peripheral blood and body fluid smears is available for checkout from the medical secretary (G306)

A set of cytochemical stains and pb/bm smears is available from the bone
marrow technologists. Individual faculty members also have teaching slides.

Foucar, K. Bone Marrow Pathology, 2nd Edition, ASCP Press, 2001.

Foucar, K, Viswanatha DS, Wilson S (Eds). Non-neoplastic disorders of bone
marrow. Atlas of non-tumor pathology. AFIP, 2008.

Swerdlow, S.H., Campo, E., Harris, N.L., Jaffe, E., Pileri, S.A., Stein, H., Thiele,
J., Vardiman, J. (Eds.): WHO Classification of Tumours Pathology of
Haematopoietic and Lymphoid Tumours, IARC, Lyon, 2008.

Keren DF, McCoy JP Jr, Carey JL (Eds.): Flow Cytometry in Clinical Diagnosis,
4rd Edition, ASCP, 2007.

Bain, BJ, Clark, DM, Lampert, IA, Wilkins, BS. Bone Marrow Pathology, 3rd
Edition, Blackwell Science, 2001.

Kjeldsberg CR: Practical Diagnosis of Hematologic Disorders, 4th Edition, ASCP,
2006.

Leonard, D Diagnostic Molecular Pathology (Volume 41 in the series “Major
Problems in Pathology”), Saunders, 2003.

Stramatoyannopoulos M, Perlmutter V. Molecular Basis of Blood Diseases, 3rd
Edition, W.B. Saunders, 2001.

Additional Resources:

Knowles DM. Neoplastic Hematopathology, 2nd Edition, Lippincott Williams &
Wilkins, 2000.

Peterson LC and Brunning RD. Chapter 37. Bone Marrow specimen
Processing, pp1391-1406.

Li C-Y and Yam LT. Chapter 38. Cytochemical, Histochemical and
Immunohistochemical Analysis of the Bone Marrow
See list of web-based resources at end of manual.
NOTE: Reading is an important component of this rotation. It is recognized that not all
of the above resources can be used nor can most be read in entirety. Use of electronic
and other resources to find and read up-to-date journal articles is also critical.
General Trainee Responsibilities during Bone Marrow Rotation
Adequate preparation of a bone marrow prior to sign out includes:
1. Aspirate smears are usually available the day before the biopsy is processed (i.e. the
day before sign-out). Ideally cases should be scanned the day before sign-out in order
to select appropriate cases in which trainees will be expected to assume a greater
degree of responsibility – please coordinate with your attending. On these cases, please
do your own differential counts to see how they compare with the technologists’ counts
on the next day. Particularly once you have some experience, the differentials should be
on the more interesting/difficult cases. Contact physician if necessary (e.g., if after
review with staff pathologists, a new acute leukemia is seen). Trainees will have
increasing responsibility for independent preview, as they are more experienced.
2. Obtain sufficient history from computer, chart or physician’s office to understand reason
for marrow being performed and to understand any coexistent disease process, drug
usage, exogenous toxins, etc. which might affect bone marrow interpretation. Look up
any appropriate laboratory data such as folate, B12, and iron (plus TIBC) in anemias or
macrocytosis, results of SPEP, UPEP, and immunofixation in evaluation of plasma cell
disorders. If possible, this should be obtained prior to initial review with staff pathologist.
The technologist’s history may or may not be sufficient.
3. Preview of peripheral blood smear, marrow aspirate smears and biopsies on all
assigned cases.
4. Gather and interpret any ancillary studies which have been performed such as flow
cytometry.
5. Review prior marrow and surgical pathology specimens where appropriate (e.g.
leukemic marrow case where looking for residual/recurrent disease, extent of prior
disease in follow-up of plasma cell neoplasia).
6. Write down description and diagnosis in pencil on template or indicate agreement or
disagreement with technologist’s comments with a check mark or other notation.
.Discuss the format of bone marrow report with the staff pathologist on service.
7. In consultation with staff pathologist, dictate reports either upon completion of sign-out or
after each case. Please use whatever method will get the cases out ASAP. See specific
guidelines on next page.
8. The staff pathologist may ask you to proof and correct the reports you have dictated. If
you will be doing this, ask the secretary not to send the report to the pathologist’s queue
(i.e. do not “final” the report). Trainee should final the report once it is proofed.
9. With increasing experience, fellows will have a more independent role in bone marrow
evaluations with increasing responsibility as designated by faculty.
10. Bone marrow report:
 Peripheral blood smear should focus on morphologic features of (1) red blood
cells, (2) leukocytes and (3) platelets. Any abnormal or atypical features
should be described in detail.

Morphologic description of bone marrow should address the following
features:
 Cellularity
 Presence of abnormal infiltrates (lymphoid aggregates, clusters of
immature myeloid cells, granuloma, metastatic tumor infiltrates, etc.)
 Myeloid-to-erythroid ratio
 Maturation of megakaryocytic, erythroid and granulocytic precursors
 Presence (and severity) of dysplasia
 Bone trabeculae
Specific Guidelines for Residents and Fellows on Bone Marrow Service
I.
Previewing
a. Urgent cases that faculty should be informed about without delay:
i. New acute leukemias.
ii. Day 14 status post chemotherapy induction for acute myeloid leukemia.
.
b. Please designate number of cells to be counted; generally 500 cell count if there
is any suspicion for a myeloid neoplasm, 300 cell count for lymphoma/myeloma
staging cases.
c. An iron stain should be ordered if there is anemia, microcytosis, macrocytosis, or
elevated RDW.
i. Please order it on the aspirate smears unless there are no spicules.
ii. If there are no spicules, order it on the touch imprint or core biopsy.
iii. Exception: An iron stain is likely not needed for anemia or abnormal indices
during induction or consolidation for acute leukemia.
II.
Preparation prior to sign-out
a. When applicable, have the most recent bone marrow report and diagnostic
bone marrow report printed out.
b. If available, diagnostic and most recent bone marrow slides should be
pulled out and reviewed and reports printed
c. When applicable, review the prior diagnosis, pertinent immunophenotype and
cytogenetics.
d. Preview the case, including the flow cytometry.
i. Arrange a time to sign-out with a faculty member so that you will have
enough time for previewing, which is very important in resident education.
ii. Be ready to discuss the case and ask questions.
III.
Immunohistochemistry and other studies
a. Order 5-10 blanks to be cut whenever immunohistochemistry studies are
ordered on our bone marrow cases.
b. Order stains through the bone marrow technologists (Audix stain line 412-8023273)
c. Please use the table for dictating the results of the immunohistochemistry
studies.
i. Transcriptions know how to format the results in the table
ii. Quick text = “HISTRPT.”
d. Please remember to justify why immunohistochemistry has been performed if
flow has also been performed.
Quick text choices: FLOW/IHC1 or FLOW/IHC2.
IV.
Quality assurance is very important
a. Assess the adequacy of aspirate smears and core biopsy: Adequate,
suboptimal, or inadequate, using the following criteria below:
Bone Marrow Adequacy Criteria:
Biopsy (trephine):
Adequate
(A)
15 mm gross length, at least 10 partially preserved intertrabecular
areas (40x)
(S)
less than 15 mm length, at least 5 partially preserved
intertrabecular areas
(I)
less than 5 mm, fewer than 5 partially preserved intertrabecular
areas
Suboptimal
Inadequate
Particle/clot:
Adequate
Suboptimal
Inadequate
(A)
(S)
(I)
at least 10 partially preserved marrow particles/areas (40x)
at least 5 partially preserved marrow particles
fewer than 5 partially preserved marrow particles
Aspirate:
Adequate
Suboptimal
Inadequate
(A)
(S)
(I)
3 or more spicules, 300 or more cells
1 or 2 spicules, 100 or more cells
no spicules, BM diff. cannot be performed (less than 100 cells)
Touch imprint:
Adequate
Suboptimal
Inadequate
(A)
(S)
(I)
300 or more cells
100 or more cells, less than 300
BM diff. cannot be performed (less than 100 cells)
V.
Dictations, proof reading, and final sign-out
a. After the initial review of a case with the hematopathologist, please dictate
the report to the best of your ability. Additional studies and final diagnosis
can be added later.
b. After you have dictated the final report, proof read it, and then arrange with the
faculty how they wish you to proceed. Some would like the slides and
paperwork.
c. Faculty specific requests.

VI.
Dr. Gibson: For normal flow interpretations, please use
“CGR_NEG_BM” and modify appropriately
Wednesday 8:30 am conference
a. The trainee on the adult bone marrow service is responsible for the 3 cases
for the Wednesday conference for the following week after sign-out with the
faculty member on BM#1 service.
b. If there is a trainee on the pediatric/ATL bone marrow service, then the trainees
should determine if that trainee is presenting a pediatric or ATL case.
c. If the trainee(s) cannot meet this expectation, it is his, her or their
responsibility to make arrangements with someone, such as the faculty
member, so that 3 cases get presented.
d. Discuss the last minute details of your cases to be presented with the
responsible faculty member on Monday, two days before the conference.
Determine if the faculty member needs to review the digital images or any other
details.
VII.
Going off service
a. Please make it clear to the responsible faculty member what the status of a case
is, what is pending, and where you have put it.
b. At the beginning of this last week on service, discuss with the responsible faculty
member who will be presenting at Wednesday 8:30 am conference. In most
cases, you will still be able to present your cases even if on another
hematopathology service.
Policy for Review of Bone Marrow Aspirates, Particle Preparations and Biopsies
Technologists will screen all smears; assess quality of specimen and quality of stain.
Technologist will inform Trainee or if no trainee, faculty when new marrow aspirates with
acute leukemia or day 14 S/P chemotherapy are ready to be reviewed. A worksheet
with the CBC data and morphology comments written in should be printed and made
available for the review with the aspirate smear and PB smear. In addition a working
draft that includes previous cases will be attached. In other cases check review bin in
the sign-out room.
Trainee/Pathologist will review aspirate smears/cases together with the history and other
clinical data on day they are received in the laboratory.
Clinicians performing marrows may also request a marrow differential or iron stain. This
will have been noted by the technologist on the form that is used to record what special
studies are being requested.
Other useful information
1. To order additional immunohistochemical stains, FISH molecular orders and all other non
stat requests on bone marrow cases call the Audix stain line 412-802-3273 and leave a
message. These are routinely picked up during normal working hours.
2. Prior slides:
 Bone marrow slides from part of 2009-present are in G325.1.
 Bone marrow slides from unknown-part of 2008 are at Iron Mountain.(see table
below)
 In the Hematology Lab, the peripheral blood slides are kept for 2 weeks and are filed
by accession number. The CBC results are in Sunquest/Mysis.
 Slides to preview for bone marrow service #1 are placed in G315. There is
also a bin for the cases ready for the technologist. Cases ready for sign out
are also placed in G315.
Flow reports are tubed to the bone marrow room G325.1 up to 5:15pm. After that, urgent cases
are delivered directly to the pathologist
Bone Marrow Rotation Checklist
including fellows.
 Orientation with Dr. Swerdlow and Dr. Gibson or his designate.
 Reviewed entire ASCP teaching set (Blood Cell Morphology).
 Reviewed aspirate smears from teaching set with Bone Marrow Technologist.
 Can recognize all normal hematopoietic cell types at all stages of maturation and knows
normal bone marrow morphology. Perform peripheral blood and bone marrow differential
counts.
 Knows phenotype of normal hematopoietic elements.
 Confidently can interpret flow cytometry data including histograms.
 Knows role of cytogenetics and molecular diagnostic studies in evaluating hematopoietic
/ lymphoid disorders in bone marrow and blood.
Learned diagnostic criteria using multiparameter approach and clinical implications
for each of the following:
Diagnosis/Finding
Observed
Actual
Case
Observed
Teaching
File Case
Read
About
MYELOPROLIFERATIVE NEOPLASMS

Chronic myelogenous leukaemia, BCR-ABL1
positive




Chronic neutrophilic leukaemia




Polycythaemia vera




Primary myelofibrosis



Essential thrombocythaemia




Chronic eosinophilic leukaemia, NOS




Myeloproliferative neoplasm, unclassifiable




MYELOID AND LYMPHOID NEOPLASMS WITH
EOSINOPHILIA AND ABNORMALITIES OF
PDGFRA, PDGFRB OR FGFR1




MYELODYSPLASTIC/MYELOPROLIFERATIVE
NEOPLASMS

Chronic myelomonocytic leukaemia




Atypical chronic myeloid leukaemia, BCR-ABL1
negative




Juvenile myelomonocytic leukaemia




Myelodysplastic/myeloproliferative neoplasm,
unclassifiable




Refractory anaemia with ring sideroblasts
associated with marked thrombocytosis





Hypoplastic myelodysplastic syndrome




MDS with fibrosis




Refractory cytopenia with unilineage dysplasia




Refractory anaemia with ring sideroblasts




Refractory cytopenia with multilineage dysplasia




Refractory anaemia with excess blasts




Myelodysplastic syndromes associated with isolated
del (5q)




ACUTE MYELOID LEUKEMIA (AML) AND
RELATED PRECURSOR NEOPLASMS




AML with recurrent genetic abnormalities




MYELODYSPLASTIC SYNDROMES
AML (promyelocytic) with t(15;17)(q22;q21);
PML-RARA




AML with t(8;21) (q22; q22); RUNX1-RUNX1T1




AML with inv(16) (p13.1q22) or t(16;16)
(p13.1;q22); CBFB-MYH11


































AML with t(9;11) (q22; q23); MLLT3-MLL


AML with t(6;9) (p23; q34); DEK-NUP214


AML with inv(3) (q21q26.2) or t(3;3) (q221;q26.2);
RPN1-EVI1


AML (megakaryoblastic) with t(1;22) (p12;q13);
RBM12-MKL1

AML with mutated NPM1



AML with mutated CEBPA


AML with myelodysplasia-related changes


Therapy-related myeloid neoplasms



Acute myeloid leukaemia, NOS
AML with minimal differentiation


AML without maturation


AML with maturation


Acute myelomonocytic leukaemia


Acute monoblastic and monocytic leukaemia


Acute erythroid leukaemia


Acute megakaryoblastic leukaemia
Acute basophilic leukaemia










































Acute panmyelosis with myelofibrosis


Blastic plasmacytoid dendritic cell neoplasm


ACUTE LEUKAEMIAS OF AMBIGUOUS
LINEAGE

Acute undifferentiated leukaemia



Mixed phenotype acute leukaemias


PRECURSOR LYMPHOID NEOPLASMS


B lymphoblastic leukaemia/lymphoma, NOS


B lymphoblastic leukaemia/lymphoma with
recurrent genetic abnormalities


T lymphoblastic leukaemia/lymphoma


Lymphoid leukaemias


Chronic lymphocytic leukemia/small
lymphocytic lymphoma


B-cell prolymphocytic leukemia


Hairy cell leukemia


T-cell prolymphocytic leukemia


T-cell large granular lymphocyte leukemia


Aggressive NK-cell leukemia


Adult T-cell leukemia/lymphoma

Plasma cell myeloma



Bone Marrow involvement in lymphoma






































Lymphoplasmacytic lymphoma


Marginal zone B-cell lymphomas


Follicular lymphoma


Mantle cell lymphoma


Diffuse large B-cell lymphoma


Intravascular large B-cell lymphoma


Burkitt lymphoma/leukemia


Hepatosplenic T-cell lymphoma


Mycosis fungoides/ Sézary syndrome


Peripheral T-cell lymphoma, unspecified


Angioimmunoblastic T-cell lymphoma


Anaplastic large cell lymphoma


Nodular lymphocyte predominant Hodgkin
lymphoma

Classical Hodgkin lymphoma



Other
Mastocytosis


BM in Post-transplant lymphoproliferative
disorder

Amyloidosis



Metastatic tumor in bone marrow






























BM changes post
chemotherapy/transplant/growth factor therapy



Non Neoplastic Disorders
Granulomas in bone marrow and differential
diagnosis


HIV associated disease associated bone
marrow changes


Autoimmune disease associated bone marrow with
increased myelofibrosis


Serous Atrophy



Red Blood Cells
Anemias, NOS


Iron Deficiency

Anemia of chronic disease

B12/folate deficiency




Hemolytic anemia


Aplastic anemia


Erythrocytosis and secondary polycythemia



White Blood Cells
Leukemoid Reaction/Non-Neoplastic
Neutrophilia


Neutropenia




























Eosinophilia


Basophilia


Monocytosis


Lymphocytosis


Infectious mononucleosis and other viral
infection


Megakaryocytes/Platelets
Thrombocytosis


Thrombocytopenia


Autoimmune thrombocytopenic purpura


Thrombotic thrombocytopenic purpura



Infectious disease
Malaria


Babesia


Anaplasmosis


PRESENTED THE FOLLOWING BONE MARROW CASES (Fellows submit presentation in
portfolio).
PHB NUMBER
DIAGNOSIS
UTILIZED THE FOLLOWING BONE MARROW RESOURCES

A set of cytochemical stains and pb/bm smears is available from the bone
marrow technologists. Individual faculty members also have teaching slides.

“Articles for Residents” black binders. Classic reference articles for classification
of leukemia, etc. Located in G323.



Foucar, K Reichard KK and Czuchlewski D. Bone Marrow Pathology, 3nd Edition,
ASCP Press, 2010.
Swerdlow, S.H., Campo, E., Harris, N.L., Jaffe, E., Pileri, S.A., Stein, H., Thiele,
J., Vardiman, J. (Eds.): WHO Classification of Tumours Pathology of
Haematopoietic and Lymphoid Tumours, 343-349, IARC, Lyon, 2008.
Bain, BJ, Clark, DM, Lampert, IA, Wilkins, BS. Bone Marrow Pathology, 3rd
Edition, Blackwell Science, 2001.

Leonard, D Diagnostic Molecular Pathology (Volume 41 in the series “Major
Problems in Pathology”), Saunders, 2003.

Foucar, K., Viswanatha, D.S., Wilson, C.S., Non-Neoplastic Disorders of Bone
Marrow, American Registry of Pathology, 2008.

There is a peripheral blood and fluid study set that can be checked out from the
Hematopathology Secretary (G306).
I have completed the Bone Marrow Checklist.
Name __________________________________________ (printed)
__________________________________________ (signature)
Date
__________________________________________
APPENDIX
5/21/15
LOCATION OF BONE MARROW RECORDS
CHP
SLIDES
UPMC
REPORTS
SLIDES
1994 – 2008
(PHB08-2859)
In Iron mountain
1996-Present:
In CoPath
Client Server.
Part 2013-Present:
PHB
(PHB13-842- present)
G325.1 PUH
Bone Marrow Room.
PHB08-2860 to
present : see
adult slides
locations.
Unknown-part 2013
(PHB13-841)
Iron Mountain.
1976-1994:
Iron Mountain.
Unknown-1976
CHP Pathology
(basement)
1930-1938,
1950-1996:
BRM
MUH (PRIOR TO MERGER)
REPORTS
REPORTS
1990-Present
In Co-path
Client Server.
Starting April, 2009
Surg path reqs
stored in the Scaife
processing area.
1981-1990:
A Stem 6th floor,
Microfiche files
1963-1981:
BRM
SLIDES
REPORTS
1983-1988 asp
1990-1995:
1991-1995 asp
and bx:
As described
Iron Mountain.
for UPMC
Unknown-1991 bx:
MUH
Surgical Pathology
files in Iron
Mountain.
1967-1982 asp:
Iron Mountain.
Unknown1990:
BRM
Forms and Templates for
Bone Marrow Service
ADULT BONE MARROW SERVICE REQUEST FORM
PHB13-
Date
ADDSYNOPTIC
Name:
Requests:






PB not available
Do full PB Diff and review
Scan PB for morphology, blasts and abnormal cells
Scan PB for blasts and abnormal cells
Scan BM smear for tumor
Do BM Diff with detailed review of smears
300 cell count
500 cell count
*default is 300 cell differential
 Order Iron Stain on biopsy/smear
 Order the following cytochemical stains:
SB
PX
PAS
CAE
DBLE (+/-fl)
 NSE (Acetate Esterase +/- fluoride)
 NSE (Butyrate Esterase +/- fluoride)
 Order the following other stains:
Stain
Specimen Date/Time
Tech
(Bx,FBM,clot...)
_______________________
________ ___________________
_______________________
________ ___________________
 Molecular:
 Other:__________________________________________________
Print full report
Pull slides
Most recent previous BM
 




First diagnostic BM
 




PH__-___________
 




PH__-___________
 




_____________________________
Pathologist/Resident
#1  or #2  or #3  or CHP 
Bone Marrow Service
--------------------------------------------------------------------------------------------------------------------Quality Assurance Check:
 Satisfactory.
Less than optimal:
 stain quality:_______________________________
BM _ : __________

differential count PB _

morphology evaluation :______________________

history incomplete/incorrect :__________________

Comment
ADULT BONE MARROW WORKSHEET
OUTSIDE ADULT BONE MARROW WORKSHEET
Technologist: ________________________________________________________________________
Clinical History:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Medications/Chemotherapy/Growth Factors:______________________________________________
______________________________________________________________________________________
DIAGNOSIS:
Part 1)
PERIPHERAL BLOOD -_________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Parts 2&3) BONE MARROW, BIOPSY,(TOUCH IMPRINTS) AND ASPIRATE (AND PARTICLE
PREPARATION)_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________________________ (See Comment)
COMMENT:_____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
DESCRIPTION:
PERIPHERAL BLOOD:
The following CBC is from ___/___/___,
CBC
Patient
.
Value
WBC ____________x10E+9/L
RBC ____________x10E+12/L
Hgb ____________g/dl
Hct ____________%
MCV ____________fl
MCH ____________pg
MCHC ____________gm/dl
RDW ____________%
PLT ____________x10E+9/L
Retic ___________%
Retic ___________x10E+12/L
Polys
___________%
Bands
___________%
Lymphs
___________%
Atyp. lymph _________%
Monos
___________%
Eos
___________%
SLIDE # ___________
Typical Normal Reference Range
(Male/Female)
(4.40 - 11.3)
(4.50 - 5.90/4.10 - 5.10)
(14.0 - 17.5/12.3 - 15.3)
(41.5 - 50.4/35.9 - 44.6)
(80.0 - 96.0)
(27.5 - 33.2)
(33.4 - 35.5)
( 150 - 450 )
( 0.5 - 1.5 )
(0.025 - 0.075)
__________(ABS)
__________(ABS)
__________(ABS)
__________(ABS)
__________(ABS)
__________(ABS)
(1.80 - 7.80)
(0.00 - 0.70)
(1.00 - 4.80)
(0.00 - 0.80)
(0.00 - 0.45)
Baso
___________%
Blasts
___________%
Promyel
___________%
Myelo
___________%
Meta
___________%
NRBC/100 WBC ___________
__________(ABS)
__________(ABS)
__________(ABS)
__________(ABS)
__________(ABS)
(0.00 - 0.20)
The peripheral blood smear was reviewed as follows:
______________________________________________________________________________
______________________________________________________________________________
RED BLOOD CELL MORPHOLOGY:
___Acanthocytes, ___Anisocytosis, ___Basophilic Stippling, ___Burr Cells,
___Howell-Jolly Bodies, ___Hypochromia, ___Macrocytes, ___Microcytes,
___Normochromic, ___Normocytic, ___Ovalocytes, ___Poikilocytosis,
___Polychromasia, ___Schistocytes, ___Spherocytes, ___Target Cells, ___Teardrops,
___Unremarkable,
_______________________________________________________________
________________________________________________________________________________
WHITE BLOOD CELL MORPHOLOGY:
_____Auer Rods, _____Blasts, _____Dohle Bodies, _____Hypogranularity,
_____Hypersegmentation, _____Pseudo-Pelger-Huet Anomaly, _____Toxic Granulation,
_____Atypical Lymphocytes, _____Unremarkable, _____Vacuoles _____________________
_________________________________________________________________________________
PLATELETS: are (increased, decreased, adequate) with (clumping, giant forms) seen.
_________________________________________________________________________________
BONE MARROW:
ADEQUACY STATEMENT:
The MARROW ASPIRATE SMEARS are (ADEQUATE, SUBOPTIMAL, INADEQUATE) for
interpretation precluding a differential). ( ___ aspirate smears and _____
imprints reviewed).
The MARROW BIOPSY is (ADEQUATE, SUBOPTIMAL, INADEQUATE) for interpretation.
THE MARROW PARTICLE PREP is (ADEQUATE, INADEQUATE) for interpretation.
“Evaluation of the bone marrow biopsy includes review of an H&E stain as
well as a PAS stain which is done, in part, to highlight the myeloids and
megakaryocytic elements, further evaluate the myeloid:erythroid ratio and
evaluate the underlying bone marrow stroma.”
BONE MARROW differential (_____ cells counted):
Bone Marrow
Differential
Blast
Promyelocyte
Myelocyte
Metamyelocyte
Band
PMN
Eos Myelo/Meta
Eos Band
Eos Seg
Basophil
Patient
Value
_____________%
_____________%
_____________%
_____________%
_____________%
_____________%
_____________%
_____________%
_____________%
_____________%
Adult
Mean
1.0
3.0
12.0
17.0
12.0
9.0
2.0
1.0
1.0
0.0
Normal
Range
( 0.0 - 2.0 )
( 2.0 - 4.0 )
( 8.0 - 16.0 )
( 10.0 - 25.0 )
( 9.0 - 18.0 )
( 7.0 - 14.0 )
( 1.0 - 4.0 )
( 0.0 - 3.0 )
( 1.0 - 2.0 )
( 0.0 - 0.2 )
touch
Monocytes
Pronormoblasts
Normoblasts
Lymphocytes
Plasma Cells
Other
Myeloid/Erythroid
_____________%
_____________%
_____________%
_____________%
_____________%
_____________%
_____________%
1.0
1.0
24.0
16.0
2.0
2.4
( 0.0 - 2.0 )
( 0.0 - 1.0 )
( 16.0 - 32.0 )
( 11.0 - 23.0 )
( 0.0 - 3.0 )
(
1.5 -
3.3 )
The MARROW is (mildly, moderately, markedly) (normocellular, hypocellular,
hypercellular)
(_____% cellular). There is stromal injury/chemotherapy effect.
_____________________________________________________________________________________
_____________________________________________________________________________________
The MYELOID/ERYTHROID RATIO is (mildly, moderately, markedly)(increased, decreased,
unremarkable, not evaluable)
_____________________________________________________________________________________
_____________________________________________________________________________________
ERYTHROID MATURATION is (complete, slight, moderate, marked, megaloblastoid,
megaloblastic, asynchronous, with dyserythropoietic forms).
_____________________________________________________________________________________
_____________________________________________________________________________________
MYELOID MATURATION is (complete, slight, moderate, marked, megaloblastoid,
megaloblastic, with dysplastic forms, with pseudo-Pelger-Huet forms, with a left
shift).
_____________________________________________________________________________________
_____________________________________________________________________________________
MEGAKARYOCYTES are (present in, absent) (mildly, moderately, markedly) (increased,
decreased, normal) numbers (with clusters, aggregates, very large aggregates present).
MEGAKARYOCYTES
include (monolobate, hypersegmented, small, non-budding, dysplastic) forms.
____________________________________________________________________________________
____________________________________________________________________________________
STAINABLE IRON is (absent, decreased, present, moderately abundant, abundant) based on
an iron stain performed on the (aspirate smear, biopsy, particle preparation).
There are (no, rare, moderate numbers of, numerous) ringed sideroblasts identified.
No focal lesions are identified. The bony trabeculae are (unremarkable, thinned,
show osteoclastic resorption, osteoblastic rimming, show new bone formation).
____________________________________________________________________________________
____________________________________________________________________________________
ANCILLARY STUDIES:
FLOW/IHC1: Medical necessity justification for the immunohistochemical stains that
were needed in addition to the flow cytometric immunophenotypic studies for the best
diagnosis possible is as follows:
The flow cytometric studies did not define the precise nature of all the cellular
elements of concern in this specimen.
The flow cytometric studies are not clearly representative of all the features
requiring evaluation in this specimen.
ADULT BONE MARROW WORKSHEET
INSIDE ADULT BONE MARROW WORKSHEET
Technologist: ________________________________________________________________________
Clinical History:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Medications/Chemotherapy/Growth Factors:______________________________________________
______________________________________________________________________________________
DIAGNOSIS:
Part 1)
PERIPHERAL BLOOD -_________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Parts 2&3) BONE MARROW, BIOPSY,(TOUCH IMPRINTS) AND ASPIRATE (AND PARTICLE
PREPARATION)_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________________________ (See Comment)
COMMENT:_____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
DESCRIPTION:
PERIPHERAL BLOOD:
CBC
Patient
.
Value
WBC ____________x10E+9/L
RBC ____________x10E+12/L
Hgb ____________g/dl
Hct ____________%
MCV ____________fl
MCH ____________pg
MCHC ____________gm/dl
RDW ____________%
PLT ____________x10E+9/L
Retic ___________%
Retic ___________x10E+12/L
Polys
___________%
Bands
___________%
Lymphs
___________%
Monos
___________%
Eos
___________%
SLIDE # ___________
UPMC-Presbyterian Normal Range
(Male/Female)
(3.8 - 10.6)
(4.13 - 5.57/3.73 - 4.89)
(12.9 - 16.9/11.6 - 14.6)
(38.0 - 48.8/34.1 - 43.3)
(82.6 - 97.4)
(27.8 - 33.4)
(32.7 - 35.5)
(11.8 - 15.2)
( 156 - 369 )
( 0.8 - 2.0/0.8 - 4.0)
(0.018 - 0.158)
__________(ABS)
__________(ABS)
__________(ABS)
__________(ABS)
__________(ABS)
__________(ABS)
(2.24 - 7.68)
(0.10 - 0.80)
(0.80 - 3.65)
(0.30 - 0.90)
(0.00 - 0.40)
Baso
___________%
Blasts
___________%
Promyel
___________%
Myelo
___________%
Meta
___________%
NRBC/100 WBC ___________
__________(ABS)
__________(ABS)
__________(ABS)
__________(ABS)
__________(ABS)
(0.00 - 0.06)
The peripheral blood smear was reviewed as follows:
______________________________________________________________________________
______________________________________________________________________________
RED BLOOD CELL MORPHOLOGY:
___Acanthocytes, ___Anisocytosis, ___Basophilic Stippling, ___Burr Cells,
___Howell-Jolly Bodies, ___Hypochromia, ___Macrocytes, ___Microcytes,
___Normochromic, ___Normocytic, ___Ovalocytes, ___Poikilocytosis,
___Polychromasia, ___Schistocytes, ___Spherocytes, ___Target Cells, ___Teardrops,
___Unremarkable, _______________________________________________________________
________________________________________________________________________________
WHITE BLOOD CELL MORPHOLOGY:
_____Auer Rods, _____Blasts, _____Dohle Bodies, _____Hypogranularity,
_____Hypersegmentation, _____Pseudo-Pelger-Huet Anomaly, _____Toxic Granulation,
_____Atypical Lymphocytes, _____Unremarkable, _____Vacuoles _____________________
_________________________________________________________________________________
PLATELETS: are (increased, decreased, adequate) with (clumping, giant forms) seen.
_________________________________________________________________________________
BONE MARROW:
ADEQUACY STATEMENT:
The MARROW ASPIRATE SMEARS are (ADEQUATE, SUBOPTIMAL, INADEQUATE) for
interpretation precluding a differential). (___ aspirate smears and _____
imprints reviewed).
The MARROW BIOPSY is (ADEQUATE, SUBOPTIMAL, INADEQUATE) for interpretation.
THE MARROW PARTICLE PREP is (ADEQUATE, INADEQUATE) for interpretation.
“Evaluation of the bone marrow biopsy includes review of an H&E stain as
well as a PAS stain which is done, in part, to highlight the myeloids and
megakaryocytic elements, further evaluate the myeloid:erythroid ratio and
evaluate the underlying bone marrow stroma.”
BONE MARROW differential (_____ cells counted):
Bone Marrow
Differential
Blast
Promyelocyte
Myelocyte
Metamyelocyte
Band
PMN
Eos Myelo/Meta
Eos Band
Eos Seg
Basophil
Monocytes
Pronormoblasts
Patient
Value
_____________%
_____________%
_____________%
_____________%
_____________%
_____________%
_____________%
_____________%
_____________%
_____________%
_____________%
_____________%
Adult
Mean
1.0
3.0
12.0
17.0
12.0
9.0
2.0
1.0
1.0
0.0
1.0
1.0
Normal
Range
( 0.0 - 2.0 )
( 2.0 - 4.0 )
( 8.0 - 16.0 )
( 10.0 - 25.0 )
( 9.0 - 18.0 )
( 7.0 - 14.0 )
( 1.0 - 4.0 )
( 0.0 - 3.0 )
( 1.0 - 2.0 )
( 0.0 - 0.2 )
( 0.0 - 2.0 )
( 0.0 - 1.0 )
touch
Normoblasts
Lymphocytes
Plasma Cells
Other
Myeloid/Erythroid
_____________%
_____________%
_____________%
_____________%
_____________%
24.0
16.0
2.0
2.4
( 16.0 - 32.0 )
( 11.0 - 23.0 )
( 0.0 - 3.0 )
(
1.5 -
3.3 )
The MARROW is (mildly, moderately, markedly) (normocellular, hypocellular,
hypercellular)
(_____% cellular). There is stromal injury/chemotherapy effect.
_____________________________________________________________________________________
_____________________________________________________________________________________
The MYELOID/ERYTHROID RATIO is (mildly, moderately, markedly)(increased, decreased,
unremarkable, not evaluable)
_____________________________________________________________________________________
_____________________________________________________________________________________
ERYTHROID MATURATION is (complete, slight, moderate, marked, megaloblastoid,
megaloblastic, asynchronous, with dyserythropoietic forms).
_____________________________________________________________________________________
_____________________________________________________________________________________
MYELOID MATURATION is (complete, slight, moderate, marked, megaloblastoid,
megaloblastic, with dysplastic forms, with pseudo-Pelger-Huet forms, with a left
shift).
_____________________________________________________________________________________
_____________________________________________________________________________________
MEGAKARYOCYTES are (present in, absent) (mildly, moderately, markedly) (increased,
decreased, normal) numbers (with clusters, aggregates, very large aggregates present).
MEGAKARYOCYTES
include (monolobate, hypersegmented, small, non-budding, dysplastic) forms.
____________________________________________________________________________________
____________________________________________________________________________________
STAINABLE IRON is (absent, decreased, present, moderately abundant, abundant) based on
an iron stain performed on the (aspirate smear, biopsy, particle preparation).
There are (no, rare, moderate numbers of, numerous) ringed sideroblasts identified.
No focal lesions are identified. The bony trabeculae are (unremarkable, thinned,
show osteoclastic resorption, osteoblastic rimming, show new bone formation).
____________________________________________________________________________________
____________________________________________________________________________________
ANCILLARY STUDIES:
The flow cytometric studies did not define the precise nature of all the cellular
elements of concern in this specimen.
The flow cytometric studies are not clearly representative of all the features
requiring evaluation in this specimen.
ANCILLARY STUDIES:
Cytochemical Stains
Histologic Section Immunohistochemistry/In situ Hybridization
CYTOCHEMICAL STAINS
Interpretation/Diagnosis (for special tests only/addenda):______
________________________________________________________________
________________________________________________________________
Results/Ancillary Studies:
Cytochemical stains were performed on: _________________________
The following results were found:
Stain
Usual Reactivity
Results
--------------------------------------------------------------------------------------------------------------Sudan Black
gran, mono
--------------------------------------------------------------------------------------------------------------Peroxidase
gran, mono
---------------------------------------------------------------------------------------------------------------PAS
diff*-gran, mono
block-lymph
diff +/- block-abnl RBC
----------------------------------------------------------------------------------------------------------------CAE
CAE-gran, mast
----------------------------------------------------------------------------------------------------------------NSE
NSE-mono, mega
NSE Positivity
Was / was not
inhibited by fluoride
--------------------------------------------------------------------------------------------------------------------
DAY 14 BONE MARROW WORKSHEET
Technologist:
_________________________________________________________________
Clinical History:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Medications/Chemotherapy/Growth Factors:__________________________________________
__________________________________________________________________________________
Specimen adequacy:
Aspirate:
Touch imprint:
Biopsy:
Particle/clot:
Bone marrow blasts:
Absent/Present ( %)/Not evaluable
Counted on aspirate/touch imprint:
Cells counted (100, 200, 300, 500, other)
Marrow cellularity:
Peripheral blood blasts:
(
Adequate/Suboptimal/Inadequate/Not
evaluable
evaluable
evaluable
evaluable
%)
Absent/Present(
%)/Slide not available.
Cells counted(100,200)
Marrow regeneration:
Erythropiesis:
Granulopoiesis:
Megakaryopoiesis:
Absent/Rare/Present/Not evaluable
Additional morphologic findings:
Clusters of immature cells
Lymphoid aggregate(s)
Granuloma(s)
Other:
Immunohistochemical stains performed to better assess marrow findings:
CD34
CD117
TDT
Other
“Medical necessity justification for the immunohistochemical stains that were needed in
addition to the flow cytometric immunophenotypic studies for the best diagnosis possible is
as follows: The flow cytometric studies did not define the precise nature of all the
cellular elements of concern in this specimen”.
Cytochemical stains performed to better assess marrow findings:
Myeloperoxidase
Non-specific (Butyrate) esterase
This report is based on morphologic evaluation of submitted bone marrow specimen and the
following completed ancillary studies:
Immunohistochemical stains
Cytochemical stains
Flow cytometric analysis (separate report attached)
Classical cytogenetic (karyotypic) analysis (separate report
attached)
Cytogenetic FISH analysis (separate report attached)
Molecular analysis (separate report attached)
Other:
The following studies are pending with results to follow:
Immunohistochemical stains
Cytochemical stains
Flow cytometric analysis
Classical cytogenetic (karyotypic) analysis
Cytogenetic FISH analysis
Molecular analysis
Other:
2 bone marrow aspirate smears and 1 touch prep reviewed.
“Evaluation of the bone marrow biopsy includes review of an H&E stain as well as a PAS
stain which is done, in part, to highlight the myeloids and megakaryocytic elements, further
evaluate the myeloid: erythroid ratio and evaluate the underlying bone marrow stroma”.
CBC
Patient
.
Value
WBC ___________ x10E+9/L
RBC ___________ x10E+12/L
Hgb ____________g/dl
Hct ____________%
MCV ___________ fl
MCH __________ pg
MCHC __________ gm/dl
RDW __________ %
PLT ___________ x10E+9/L
Retic ___________%
Retic ___________x10E+12/L
Polys
__________%
Bands
___________%
Lymphs
___________%
Monos
___________%
Eos
__________%
Baso
__________%
SLIDE # ___________
UPMC-Presbyterian Normal Range
(Male/Female)
(3.8 - 10.6)
(4.13 - 5.57/3.73 - 4.89)
(12.9 - 16.9/11.6 - 14.6)
(38.0 - 48.8/34.1 - 43.3)
(82.6 - 97.4)
(27.8 - 33.4)
(32.7 - 35.5)
(11.8 - 15.2)
( 156 - 369 )
( 0.8 - 2.0/0.8 - 4.0)
(0.018 - 0.158)
__________(ABS)
__________(ABS)
__________(ABS)
__________(ABS)
__________(ABS)
__________(ABS)
__________(ABS)
(2.24 - 7.68)
(0.10 - 0.80)
(0.80 - 3.65)
(0.30 - 0.90)
(0.00 - 0.40)
(0.00 - 0.06)
Blasts
_________%
Promyel
__________%
Myelo
__________%
Meta
__________%
NRBC/100 WBC __________
__________(ABS)
__________(ABS)
__________(ABS)
__________(ABS)
Recommendations for Consistent Terminology in Hematopathology Reports
1. Use the 2008 WHO Classification (see the monograph)
2. Leukemic follow-up marrows
a. History should always state: Day
status post chemotherapy (or status post
transplant) for abbreviated disease name e.g. AML, promyelocytic
i.
If time unknown, delete “day
.”
*Remember day status post chemotherapy refers to days following initiation of therapy.
A. Preferably a similar statement should also be in the diagnosis following the initial diagnostic line
e.g.
Bone marrow, biopsy and aspirate-A. Markedly hypocellular marrow with chemotherapy effect
B. (Day 7 status post chemotherapy for AML).
B. If history of leukemia is remote, history (and if desired, diagnosis) should state:
“Status post previous diagnosis of _____________________”.
3. Whenever appropriate, state, in comment, how the marrow compares to the immediate previous
one and give the previous marrow number; e.g., “compared to the patient’s previous marrow
(PHB11-XXXX), blasts are not increased.”
4. Whenever any ancillary studies or special stains are reported, be sure to include an interpretation
and not just a statement of the result. On cases without histologic material, be sure to dictate an
interpretation including a summary of the results, which will be typed in the space where diagnosis
usually goes.
For example, if an addendum is issued with the results of a reticulin stain, do not include just,
“The reticulin stain shows a marked increase in reticulin fibers”, also an interpretation
(i.e. “This strongly supports the diagnosis in this case of a myeloproliferative
neoplasm”).
5. Abnormal plasma cell proliferations should be given as specific a diagnosis as possible.
A.
B.
C.
D.
E.
Plasma cell myeloma (use if possible).
Plasma cell neoplasm (if definite neoplasm, but uncertain if myeloma).
Plasmacytosis (with qualifier if the diagnosis of a neoplasm cannot be made).
Plasmacytoma (a non-myeloma plasma cell neoplasm).
Remember, plasma cell dyscrasia includes non-neoplastic disorders as well as plasma cell
neoplasms.
Case number:___________________________
Resident Bone Marrow Differential count Worksheet
(_______ cells counted)
Blasts
Promyelocytes
Myelocytes
Metamyelocytes
Bands/Seg Neutrophils
Erythroid cells
Lymphocytes
Eosinophils
Basophils
Monocytes
Plasma cells
Myeloid:erythroid ratio
Signature____________________________________________________
Date: ___________________________
Pathologist initials ____________
Protocol for the Examination of Specimens From Patients With
Hematopoietic Neoplasms Involving the Bone Marrow
Based on AJCC/UICC TNM, 7th Edition
Protocol web posting date: June 2012
Procedures
 Bone marrow aspiration
 Bone marrow core (trephine) biopsy
Authors
Jerry W. Hussong, MD, DDS, FCAP*
Cedars-Sinai Medical Center, Los Angeles, California
Daniel A. Arber, MD
Stanford University School of Medicine, Stanford, California
Kyle T. Bradley MD, MS, FCAP
Emory University Hospital, Atlanta, Georgia
Michael S. Brown, MD, FCAP
Yellowstone Pathology Institute Inc, Billings, Montana
Chung-Che Chang, MD, PhD, FCAP
The Methodist Hospital, Houston, Texas
Monica E. de Baca, MD, FCAP
Physicians Laboratory Ltd, Sioux Falls, South Dakota
David W. Ellis, MBBS, FRCPA
Flinders Medical Centre, Bedford Park, South Australia
Kathryn Foucar, MD, FCAP
University of New Mexico, Albuquerque, New Mexico
Eric D. Hsi, MD, FCAP
Cleveland Clinic Foundation, Cleveland, Ohio
Elaine S. Jaffe, MD
National Cancer Institute, Bethesda, Maryland
Michael Lill, MB, BS, FRACP, FRCPA
Stephen P. McClure, MD
Presbyterian Pathology Group, Charlotte, North Carolina
L. Jeffrey Medeiros, MD, FCAP
MD Anderson Cancer Center, Houston, Texas
Sherrie L. Perkins, MD, PhD, FCAP
University of Utah Health Sciences Center, Salt Lake City, Utah
For the Members of the Cancer Committee, College of American Pathologists
* Denotes the primary and senior author. All other contributing authors are listed alphabetically.
Surgical Pathology Cancer Case Summary
Protocol web posting date: June 2012
BONE MARROW: Aspiration, Core (Trephine) Biopsy
Select a single response unless otherwise indicated.
Specimen (select all that apply) (Note A)
___ Peripheral blood smear
___ Bone marrow aspiration
___ Bone marrow aspirate clot (cell block)
___ Bone marrow core (trephine) biopsy
___ Bone marrow core touch preparation (imprint)
___ Other (specify): ___________________________
___ Not specified
Procedure (select all that apply)
___ Aspiration
___ Biopsy
___ Other (specify): ___________________________
___ Not specified
Aspiration Site (if performed) (select all that apply) (Note B)
___ Right posterior iliac crest
___ Left posterior iliac crest
___ Sternum
___ Other (specify): ___________________________
___ Not specified
Biopsy Site (if performed) (select all that apply) (Note B)
___ Right posterior iliac crest
___ Left posterior iliac crest
___ Other (specify): ___________________________
___ Not specified
Histologic Type (Note C)
1
Note: The following is a partial list of the 2008 World Health Organization (WHO) classification and includes those neoplasms
seen in bone marrow specimens.
___ Histologic type cannot be assessed
Myeloproliferative Neoplasms
___ Chronic myelogenous leukemia, BCR-ABL1 positive
___ Chronic neutrophilia leukemia
___ Polycythemia vera
___ Primary myelofibrosis
___ Essential thrombocythemia
___ Chronic eosinophilic leukemia, not otherwise specified (NOS)
___ Mastocytosis (specify type): ______________________
___ Myeloproliferative neoplasm, unclassifiable
Myeloid and Lymphoid Neoplasms With Eosinophilia and Abnormalities of PDGFRA, PDGFRB and FGFR1
___ Myeloid or lymphoid neoplasm with PDGFRA rearrangement
___ Myeloid neoplasm with PDGFRB rearrangement
___ Myeloid or lymphoid neoplasm with FGFR1 abnormalities
Myelodysplastic/Myeloproliferative Neoplasms
___ Chronic myelomonocytic leukemia
___ Atypical chronic myeloid leukemia BCR-ABL1 negative
___ Juvenile myelomonocytic leukemia
___ Myelodysplastic/myeloproliferative neoplasm, unclassifiable
___ Refractory anemia with ring sideroblasts associated with marked thrombocytosis
___ Refractory anemia
___ Refractory neutropenia
___ Refractory thrombocytopenia
___ Refractory anemia with ring sideroblasts
___ Refractory cytopenia with multilineage dysplasia
___ Refractory anemia with excess blasts
___ Myelodysplastic syndrome associated with isolated del(5q)
___ Myelodysplastic syndrome, unclassifiable
___ Refractory cytopenia of childhood
Acute Myeloid Leukemia (AML) With Recurrent Genetic Abnormalities
___ AML with t(8;21)(q22;q22); RUNX1-RUNX1T1
___ AML with inv(16)(p13.1q22) or t(16;16)(p13.1;q22); CBFB-MYH11
___ Acute promyelocytic leukemia with t(15;17)(q22;q12); PML-RARA
___ AML with t(9;11)(p22;q23); MLLT3-MLL
___ AML with t(6;9)(p23;q34); DEK-NUP214
___ AML with inv(3)(q21q26.2) or t(3;3)(q21;q26.2); RPN1-EVI1
___ AML (megakaryoblastic) with t(1;22)(p13;q13); RBM15-MKL1
___ AML with mutated NPM1
___ AML with mutated CEBPA
Acute Myeloid Leukemia With Myelodysplasia-Related Changes (select all that apply)
___ Multilineage dysplasia
___ Prior myelodysplastic syndrome
___ Myelodysplasia-related cytogenetic abnormalities
Therapy-Related Myeloid Neoplasms
___ Therapy-related AML
___ Therapy-related myelodysplastic syndrome
___ Therapy-related myelodysplastic/myeloproliferative neoplasm
Acute Myeloid Leukemia, NOS
___ AML with minimal differentiation
___ AML without maturation
___ AML with maturation
___ Acute myelomonocytic leukemia
___ Acute monoblastic/monocytic leukemia
___ Acute erythroid leukemia
___ Acute megakaryocytic leukemia
___ Acute basophilic leukemia
___ Acute panmyelosis with myelofibrosis
___ AML, NOS#
Myeloid Proliferations Related to Down Syndrome
___ Transient abnormal myelopoiesis
___ Myeloid leukemia associated with Down syndrome
Acute Leukemias of Ambiguous Lineage
___ Acute undifferentiated leukemia
___ Mixed phenotype acute leukemia with t(9;22)(q34;q11.2); BCR-ABL1
___ Mixed phenotype acute leukemia with t(v;11q23); MLL rearranged
___ Mixed phenotype acute leukemia, B/myeloid, NOS
___ Mixed phenotype acute leukemia, T/myeloid, NOS
___ Mixed phenotype acute leukemia, NOS, rare types (specify type): _____________
___ Natural killer (NK) cell lymphoblastic leukemia/lymphoma
Other Myeloid Leukemias
___ Blastic plasmacytoid dendritic cell neoplasm
Precursor Lymphoid Neoplasms
#
___ B lymphoblastic leukemia/lymphoma, NOS
___ B lymphoblastic leukemia/lymphoma with t(9;22)(q34;q11.2); BCR-ABL1
___ B lymphoblastic leukemia/lymphoma with t(v;11q23); MLL rearranged
___ B lymphoblastic leukemia/lymphoma with t(12;21)(p13;q22); TEL-AML1 (ETV6-RUNX1)
___ B lymphoblastic leukemia/lymphoma with hyperdiploidy
___ B lymphoblastic leukemia/lymphoma with hypodiploidy (hypodiploid ALL)
___ B lymphoblastic leukemia/lymphoma with t(5;14)(q31;q32); IL3-IGH
___ B lymphoblastic leukemia/lymphoma with t(1;19)(q23;p13.3); E2A-PBX1 (TCF3-PBX1)
___ T lymphoblastic leukemia/lymphoma
Mature B-Cell Neoplasms
___ Chronic lymphocytic leukemia/small lymphocytic lymphoma
___ B-cell prolymphocytic leukemia
___ Splenic B-cell marginal zone lymphoma
___ Hairy cell leukemia
___ Splenic B-cell lymphoma/leukemia, unclassifiable
___ Splenic diffuse red pulp small B-cell lymphoma
___ Hairy cell leukemia-variant
___ Lymphoplasmacytic lymphoma
___ Plasma cell myeloma
___ Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma)
___ Follicular lymphoma
___ Mantle cell lymphoma
___ Diffuse large B-cell lymphoma (DLBCL), NOS
___ T cell/histiocyte-rich large B-cell lymphoma
___ Primary cutaneous DLBCL, leg type
___ Epstein-Barr virus (EBV)-positive DLBCL of the elderly
___ DLBCL associated with chronic inflammation
___ Lymphomatoid granulomatosis
___ Anaplastic lymphoma kinase (ALK)-positive large B-cell lymphoma
___ Plasmablastic lymphoma
___ Large B-cell lymphoma arising in HHV8-associated multicentric Castleman disease
___ Burkitt lymphoma
___ B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma and
Burkitt lymphoma
___ B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma and
classical Hodgkin lymphoma
___ B-cell lymphoma, NOS
___ Other (specify): ____________________________
Mature T- and NK-cell Neoplasms
___ T-cell lymphoma, subtype cannot be determined (Note: not a category within the WHO
classification)
___ T-cell prolymphocytic leukemia
___ T-cell large granular lymphocytic leukemia
___ Chronic lymphoproliferative disorder of NK cells
___ Aggressive NK-cell leukemia
___ Adult T-cell leukemia/lymphoma
___ Extranodal NK/T-cell lymphoma, nasal type
___ Enteropathy-associated T-cell lymphoma
___ Hepatosplenic T-cell lymphoma
___ Mycosis fungoides
___ Peripheral T-cell lymphoma, NOS
___ Angioimmunoblastic T-cell lymphoma
___ Anaplastic large cell lymphoma, ALK-positive
___ Anaplastic large cell lymphoma, ALK-negative
Hodgkin Lymphoma
___ Nodular lymphocyte predominant Hodgkin lymphoma
___ Classical Hodgkin lymphoma
Histiocytic and Dendritic Cell Neoplasms
___ Histiocytic sarcoma
___ Langerhans cell histiocytosis
___ Langerhans cell sarcoma
___ Interdigitating dendritic cell sarcoma
___ Follicular dendritic cell sarcoma
___ Disseminated juvenile xanthogranuloma
___ Histiocytic neoplasm, NOS
Posttransplant Lymphoproliferative Disorders (PTLD) ##
Early lesions:
___ Plasmacytic hyperplasia
___ Infectious mononucleosis-like PTLD
___ Polymorphic PTLD
___ Monomorphic PTLD (B- and T/NK-cell types)
Specify subtype: ________________________
___ Classical Hodgkin lymphoma type PTLD###
___ Other (specify): ____________________________
Note: Italicized histologic types denote provisional entities in the 2008 WHO classification.
#
An initial diagnosis of “AML, NOS” or “B lymphoblastic leukemia/lymphoma, NOS” may need to be given before the cytogenetic
results are available or for cases that do not meet criteria for other leukemia subtypes.
##
These disorders are listed for completeness, but not all of them represent frank lymphomas.
###
Classical Hodgkin lymphoma type PTLD can be reported using either this protocol or the separate College of American
2
Pathologists protocol for Hodgkin lymphoma.
+ Additional Pathologic Findings
+ Specify: _______________________________________
+ Cytochemical/Special Stains (Note D)
+ ___ Performed
+ Specify stains and results: __________________________________
______________________________________________________
+ ___ Not performed
Immunophenotyping (flow cytometry and/or immunohistochemistry) (Note E)
___ Performed, see separate report: ___________________
___ Performed
Specify method(s) and results: ______________________________
_____________________________________________________
___ Not performed
Cytogenetic Studies (Note F)
___ Performed, see separate report: ___________________
___ Performed
_____________________________________________________
___ Not performed
+ Fluorescence In Situ Hybridization (Note F)
+ ___ Performed, see separate report: ___________________
+ ___ Performed
+ Specify method(s) and results: ______________________________
_____________________________________________________
+ ___ Not performed
+ Molecular Genetic Studies (Note F)
+ ___ Performed, see separate report: ___________________
+ ___ Performed
_____________________________________________________
+ ___ Not performed
+ Comment(s)
+ Data elements preceded by this symbol are not required. However, these elements may be
clinically important but are not yet validated or regularly used in patient management.
Explanatory Notes
A. Specimen
Complete evaluation of hematopoietic disorders involving the bone marrow requires integration
of multiple pieces of data, including the clinical history, pertinent laboratory studies (eg,
complete blood count [CBC], serum lactate dehydrogenase [LDH], and beta-2-microglobulin
levels, serum protein electrophoresis, and immunofixation results), and a satisfactory peripheral
blood smear and bone marrow specimen. In most instances, this requires receiving a
peripheral blood smear, bone marrow aspirate specimen, an aspirate clot section (cell block),
and a bone marrow core biopsy.3 Touch preparations (imprints) of the biopsy specimen are
also very helpful. The World Health Organization (WHO) classification recommends performing
a 200-cell differential count on peripheral blood smears and a 500-cell differential count on bone
marrow aspirate specimens in the evaluation of hematopoietic disorders.1 This will allow
adequate evaluation of the cellular elements within the peripheral blood and bone marrow.
In addition, submission of bone marrow (usually aspirate) material for flow cytometry
immunophenotyping, cytogenetic studies, fluorescence in situ hybridization (FISH), and
molecular studies is often necessary. The guidelines that follow are suggested for handling of
bone marrow specimens:
 The number of stained and unstained peripheral blood, bone marrow aspirate, and bone
marrow core biopsy touch preparation smears should be recorded.
 The length of the bone marrow core biopsy(s) should be recorded.
 For conventional cytogenetic studies, a bone marrow aspirate specimen received in a
sodium heparin tube is ideal, but fresh specimens submitted in saline or RPMI transport
medium is sufficient.
 For immunophenotyping by flow cytometry, a bone marrow aspirate specimen received in an
ACD tube (yellow top tube) or EDTA tube (lavender top tube) is preferred.
 Bone marrow core biopsy specimens require decalcification, and care must be taken not to
under- or over-decalcify the specimen, as it will impact the ability to cut and interpret the
histologic sections and may interfere with immunohistochemical staining. Formic acid
decalcification procedures can also degrade DNA, whereas EDTA decalcification may allow
for preservation of DNA for polymerase chain reaction (PCR) studies. EDTA decalcification,
however, is slower than acid decalcification techniques.
 Fixation:
o Zinc formalin or B5 fixatives produce superior cytologic detail but are not suitable for
DNA extraction and impair some immunostains (eg, CD30). B5 has the additional
limitation of requiring proper hazardous-materials disposal.
o Formalin fixation is preferable in many situations, as it allows for many ancillary tests
such as molecular/genetic studies, in-situ hybridization, and immunophenotyping.
o Over-fixation (ie, more than 24 hours in formalin, more than 4 hours in zinc formalin or
B5) should be avoided for optimal immunophenotypic reactivity.
Care must be taken to ensure that high-quality specimens and sections are obtained for each
bone marrow specimen. Often this requires working hand-in-hand with clinical colleagues to
achieve this goal. In addition to being used for the diagnosis of primary hematopoietic
disorders, bone marrow examination is often utilized as part of the pathologic staging of many
hematopoietic neoplasms, including Hodgkin and non-Hodgkin lymphomas.3-5 Bone marrow
involvement identified within staging biopsy specimens typically indicates stage IV disease
within the Ann Arbor staging system utilized by the American Joint Committee on Cancer
(AJCC)6 and the International Union Against Cancer (UICC).7 For multiple myeloma, the Durie-
Salmon staging system is recommended by the AJCC.8 Both staging systems are shown
below. In pediatric patients, the St. Jude staging system is commonly used.9
AJCC/UICC Staging for Non-Hodgkin Lymphomas
Stage I
Stage II
Stage III
Stage IV
Involvement of a single lymph node region (I), or localized involvement of a
single extralymphatic organ or site in the absence of any lymph node
involvement (IE).#, ##
Involvement of 2 or more lymph node regions on the same side of the diaphragm
(II), or localized involvement of a single extralymphatic organ or site in
association with regional lymph node involvement with or without involvement of
other lymph node regions on the same side of the diaphragm (IIE).##,###
Involvement of lymph node regions on both sides of the diaphragm (III), which
also may be accompanied by extralymphatic extension in association with
adjacent lymph node involvement (IIIE) or by involvement of the spleen (IIIS) or
both (IIIE+S).##,###,^
Diffuse or disseminated involvement of 1 or more extralymphatic organs, with or
without associated lymph node involvement; or isolated extralymphatic organ
involvement in the absence of adjacent regional lymph node involvement, but in
conjunction with disease in distant site(s). Stage IV includes any involvement of
the liver, bone marrow, or nodular involvement of the lung(s) or cerebral spinal
fluid. ##,###,^
#
Multifocal involvement of a single extralymphatic organ is classified as stage IE and not stage
IV.
##
For all stages, tumor bulk greater than 10 to 15 cm is an unfavorable prognostic factor.
###
The number of lymph node regions involved may be indicated by a subscript: eg, II3. For
stages II to IV, involvement of more than 2 sites is an unfavorable prognostic factor.
^ For stages III to IV, a large mediastinal mass is an unfavorable prognostic factor.
Note: Direct spread of a lymphoma into adjacent tissues or organs does not influence
classification of stage.
AJCC/UICC Staging for Plasma Cell Myeloma
Stage I
Hemoglobin greater than 10.0 g/dL (100 g/L)
Serum calcium 12 mg/dL or less (3.0 mmol/L)
Normal bone x-rays or a solitary bone lesion
IgG less than 5 g/dL (50 g/L)
IgA less than 3 g/dL (30 g/L)
Urine M-protein less than 4 g/24 hours
Test
Hgb
Serium calcium
IgG
IgA
Stage III
US
>10.0g/dL
12 mg/dL or less
< 5g/dL
<3 g/dL
One or more of the following are included:
SI
>100 g/L
3.0 mmol/L or less
<50 g/L
<30 g/L
Hemoglobin less than 8.5 g/dL (85 g/L)
Serum calcium greater than 12 mg/dL (3.0 mmol/L)
Advanced lytic bone lesions
IgG greater than 7 g/dL (70 g/L)
IgA greater than 5 g/dL (50 g/L)
Urine M-protein greater than 12 g/24 hours
Test
Hemoglobin
Serium calcium
IgG
IgA
Stage II
US
<8.5 g/dL
>12 mg/dL
>7g/dL
>5 g/dL
SI
<85 g/L
>3.0 mmol/L
>70 g/L
>50 g/L
Disease fitting neither stage I nor stage III
Note: Patients are further classified as (A) serum creatinine less than 2.0 mg/dL (177 mmol/L),
or (B) serum creatinine 2.0 mg/dL (177 mmol/L) or greater. The median survival for stage IA
disease is about 5 years, and that for stage IIIB disease is 15 months. These predicted
survivals, however, may underestimate expected survival for these patient populations with
modern therapy.
B. Aspiration/Biopsy Site
Bone marrow sampling (aspiration and trephine core biopsy) is usually performed at the
posterior iliac crest.3 Aspirations and biopsies may be unilateral or bilateral, depending on the
indication for the bone marrow biopsy as well as clinician preference. Rarely, a sternal
aspiration may be performed if only a bone marrow aspirate specimen is necessary. Sternal
aspirations should only be considered as a last resort and should be performed only by persons
with extensive experience with this procedure. Occasionally, the anterior iliac crest or tibia may
be the site of the biopsy, depending on patient age and other unique characteristics of the
patient.
C. Histologic Type
This protocol recommends assigning histologic type based on the WHO classification of
lymphoid neoplasms.1 Originally published in 2001 and revised and updated in 2008, this
classification incorporates the morphologic, immunophenotypic, cytogenetic, and molecular
findings into the final diagnosis. Whereas histologic examination remains of paramount
importance, many neoplasms will require the use of these ancillary studies to arrive at the
correct diagnosis.10-15 It may not be possible to provide a specific lymphoma diagnosis with
bone marrow examination, particularly for patients in whom the bone marrow is the first
identified site of involvement. Some of the entities provided in the case summary may be
extremely uncommon in the bone marrow or may have not been described but are listed for
completeness.
D. Cytochemical/Special Stains
Numerous cytochemical or special stains may be utilized in the diagnosis of hematopoietic
neoplasms involving the bone marrow.3 An iron (Prussian blue) stain is paramount in the
evaluation of myelodysplastic syndromes and some myeloproliferative disorders. A reticulin
stain is necessary for the diagnosis of some myeloproliferative disorders but may be valuable in
evaluation of numerous other disorders such as hairy cell leukemia. Cytochemical stain for
myeloperoxidase is rapid, convenient, and helpful for the assessment of myeloid neoplasms.
Cytochemical stains for leukocyte alkaline phosphatase, and naphthol-ASD chloroacetate
esterase provide information related to cell origin or specific disease states. Cytochemical
stains, however, are no longer required for the diagnosis of most disorders.
E. Immunophenotyping by Flow Cytometry and/or
Immunohistochemistry
Immunophenotyping of bone marrow specimens can be performed by flow cytometry10 or
immunohistochemistry.11 Each has advantages and disadvantages. Flow cytometry is rapid
(hours), quantitative, and allows multiple antigens to be evaluated on the same cell
simultaneously. Flow cytometry may also allow for the detection of minimal residual disease,
especially in situations in which there is a unique expression pattern. Antigen reactivity,
however, cannot be correlated with architecture or cytologic features. In patients from whom a
dry tap is obtained, an additional bone marrow core biopsy submitted fresh in transport medium
can be disaggregated and utilized for flow cytometry immunophenotyping.
Immunohistochemistry requires hours/days to perform, quantitation is subjective, but importantly
it allows correlation of antigen expression with architecture and cytology. Not all antibodies are
available for immunohistochemistry, particularly in fixed tissues, but one of its advantages is that
it can be performed on archival tissue. Both techniques can provide diagnostic, prognostic, and
therapeutic information. Documentation of expression of antigens such as CD20, CD33, and
CD52 by the neoplastic population can aid the clinician in selection of potential therapeutic
options such as monoclonal antibody therapy. The specific immunophenotypes for individual
hematopoietic disorders involving the bone marrow are readily available within the WHO
Classification of Tumours of Haematopoietic and Lymphoid Tissues as well as many other
hematopathology textbooks.1,3,5
F. Cytogenetic and Molecular Genetic Studies
Within the WHO classification of hematopoietic disorders, significant emphasis has been placed
on cytogenetic and molecular genetic studies. More than ever before, specific cytogenetic
findings are helpful for the diagnosis of specific neoplasms and disease states.12-16 In fact,
many acute leukemias are currently defined based upon their specific cytogenetic
abnormalities.1 Given the importance now placed upon knowing the cytogenetic or molecular
results (as determined by karyotyping, FISH, or PCR results) it is of paramount importance that
care is taken to evaluate the need for these studies at the time of biopsy. FISH studies can be
also performed on air-dried unfixed slides, and in some cases DNA can be scraped off air-dried
unfixed slides for molecular studies. Since karyotyping requires growing viable cells in culture, it
is necessary to submit fresh specimens promptly to help ensure the best opportunity for a
successful study.
References
1. Swerdlow S, Campo E, Harris N, Jaffe E, et al, eds. WHO Classification of Tumours of
Haematopoietic and Lymphoid Tissues. Geneva, Switzerland: WHO Press; 2008.
2. Hussong JW, Arber DA, Bradley KT, et al. Protocol for the examination of specimens
from patients with Hodgkin lymphoma. In: Reporting on Cancer Specimens: Case
Summaries and Background Documentation. Northfield, IL: College of American
Pathologists; 2009.
3. Foucar K, ed. Bone Marrow Pathology. Chicago, IL: ASCP Press; 2001.
4. Zhang Q, Foucar K. Bone marrow involvement by Hodgkin and non-Hodgkin
lymphomas. Hematol Oncol Clin North Am. 2009;23(4):873-902.
5. Hsi E, Goldblum J, eds. Hematopathology. Philadelphia, PA: Churchill Livingstone
Elsevier; 2007.
6. Lymphoid neoplasms. In: Edge SB, Byrd DR, Carducci MA, Compton CC, eds. AJCC
Cancer Staging Manual. 7th ed. New York, NY: Springer; 2009.
7. Sobin LH, Gospodarowicz M, Wittekind Ch, eds. UICC TNM Classification of Malignant
Tumours. 7th ed. New York, NY: Wiley-Liss; 2009.
8. Durie B, Salmon S. A clinical staging system for multiple myeloma: correlation of
measured myeloma mass with presenting clinical features, response to treatment, and
survival. Cancer. 1975;36(3):842-854.
9. Cairo et al. Non-Hodgkin’s lymphoma in children. In: Kufe P, Weishelbuam R, et al, eds.
Cancer Medicine. 7th ed. London: BC Decker; 2006:1962-1975.
10. Craig F, Foon K. Flow cytometric immunophenotyping for hematologic neoplasms.
Blood. 2008;111(8):3941-3967.
11. Jaffe E, Banks P, Nathwani B, et al. Recommendations for the reporting of lymphoid
neoplasms: a report from the Association of Directors of Anatomic and Surgical
Pathology. Mod Pathol. 2004;17(1):131-135.
12. Bagg A. Molecular diagnosis in lymphomas. Curr Oncol Rep. 2004;6(5):369-379.
13. Merker J, Arber D. Molecular diagnostics of non-Hodgkin lymphoma. Expert Opin Med
Diagn. 2007;1(1):47-63.
14. Bagg A. Role of molecular studies in the classification of lymphoma. Expert Rev Mol
Diagn. 2004;4(1):83-97.
15. Sen F, Vega F, Medeiros LJ. Molecular genetic methods in the diagnosis of hematologic
neoplasms. Semin Diagn Pathol. 2002;19(2):72-93.
16. Weinberg O, Seetharam M, et al. Clinical characterization of acute myeloid leukemia
with myelodysplastic-related changes as defined by the 2008 WHO classification
system. Blood. 2009;113(9):1906-1908.
Bone Marrow Laboratory
Test Specifications
TEST SPECIFICATIONS: BONE MARROW LABORATORY
Bone Marrow Aspirate Smears, Bone Marrow Particle Preparation, and
Bone Marrow Biopsy
DELIVER ALL SAMPLES DIRECTLY TO THE FLOW CYTOMETRY LABORATORY
CLB
Room 9032
3477 Euler Way
Phone: 412-864-6173
Fax: 412-864-6102
BONE MARROW LABORATORY HOURS OF OPERATION
Monday through Friday: 8:00am to 5:00pm. The bone marrow specimens can be sent anytime. However
they will be processed the following working day if received after hours of operation. The laboratory is
th
also closed on the following holidays: New Years Day, Martin Luther King Day, Memorial Day, July 4 ,
Labor Day, Thanksgiving Day, and Christmas Day.
SPECIAL INSTRUCTIONS
 Send a completed requisition.
 Call the Clinical Flow Cytometry Laboratory (412-864-6173) first before sending, to make prior
arrangements about where to deliver.
 In packaging bone marrows, please:
1. Tightly close the biopsy container. Keep container upright.
2. MARK THE DATE AND TIME THE BIOPSY WAS PLACED IN THE B-PLUS FIXATIVE – on the
container.
3. Package slides separately from the biopsy specimen (to avoid vapor fixation of the slides).
 Use adequate safety measures when transporting specimens.
BONE MARROW EXAMINATION TEST DESCRIPTIONS
Bone marrow examinations may include aspiration with smears, particle preparations or clot sections and
biopsies. Aspirate smears are most useful to examine the cytological detail of the marrow elements and
for cytochemical and immunocytochemical stains. The aspirated material may also be used for culture,
flow cytometric immunophenotyping, cytogenetic, molecular, and other special studies.
The particle preparation represents non-decalcified tissue sections of filtered bone marrow aspirate
spicules. This allows for histopathologic analysis of a large volume of marrow with excellent morphology
and an intact architecture so features such as cellularity can be easily assessed. It is suitable for a wide
range of special stains including immunohistologic stains.
Bone marrow core biopsies are decalcified, sectioned, and routinely stained with H&E stain. Biopsy
specimens are used to evaluate cellularity, hematopoiesis, non-aspirable lesions to see the topographical
relationship of focal lesions to the bony trabeculae, and for evaluation of bone and vessels.
BONE MARROW ASPIRATE SMEAR SPECIMEN REQUIREMENTS
 10-20 bone marrow slides should be made at the bedside from the first syringe pulled. Label each
slide with name, date, and time of collection. The number of slides sent will vary depending on the
tests requested. Send the slides in either durable cardboard slide holders or plastic slide holders
accompanied by a requisition.
 If bilateral (right and left hips) bone marrows are done, then label slides left or right hip.
 Send the slides in either durable cardboard slide holders or plastic slide holders. The number of
slides sent will vary depending on the test requested.
 For a basic bone marrow aspirate interpretation based on Wright-Giemsa stains, send two labeled
slides plus a recent CBC/differential result and the corresponding peripheral blood smear.

If cytochemical or iron stains are requested, the following is a list of the minimum required number of
unstained slides that should be sent. Send one additional slide for a Wright-Giemsa stain in all cases.
In addition, extra unstained slides are useful if any stains need to be repeated.
1 SLIDE:
Iron Stain
Naphthyl AS-D Chloroacetate esterase stain (CAE)
Myeloperoxidase cytochemical stain (MPO)
Sudan Black Stain
Periodic Acid Schiff Stain (PAS)
2 SLIDES:
Non-specific Alpha Naphthol Acetate Esterase Stain (NSE)
Double Esterase Stain (NSE+CAE)
If there are any questions regarding cytochemical stains call the Special Testing Laboratory at
(412) 864-6179.
BONE MARROW PARTICLE PREPARATION SPECIMEN REQUIREMENTS
 Five milliliters of bone marrow aspirate (preferably from the first or second syringe), placed in a yellow
top (ACD) Vacutainer tube.
 Store at room temperature.
 The material for the particle preparation will be filtered, fixed, and processed by the bone marrow and
histology laboratories, at UPMC Oakland.
 In addition submit two aspirate smears, the most recent CBC/differential and corresponding
peripheral blood smear.
BONE MARROW BIOPSY SPECIMEN REQUIREMENTS
 4-6 touch preparations of the biopsy specimen (3 imprints on each slide) made at the bedside. Label
each slide with patient's name, date, and time of collection.
 Place the biopsy into B-Plus fixative. MARK THE TIME AND DATE THE BIOPSY WAS PLACED IN
THE B-PLUS FIXATIVE ON THE CONTAINER. The B-Plus fixed biopsy should be delivered to the
laboratory the same day it is done. Prolonged fixation in B-Plus Fixative makes the biopsy difficult to
process.
 If performing bilateral (right and left hips) biopsies, each biopsy must be placed in SEPARATE B-Plus
fixative containers and labeled left or right hip.
 In addition submit two aspirate smears, the most recent CBC/differential and corresponding
peripheral blood smear.
WARNING: B-Plus fixative contains formaldehyde. Formaldehyde is a carcinogen, irritant, and
highly toxic. Avoid contact with eyes, skin, and clothing. Do not inhale.
CONTACTS, DIVISION OF HEMATOPATHOLOGY
Steven Swerdlow, M.D.
Director, Division of Hematopathology
Miroslav Djokic, M.D.
Director, Adult Bone Marrow Service
Celina Fortunato
Lead technologist, Bone Marrow Lab
Rev 4/13
(412) 647-5191
(412) 692-2128
(412) 647-0263
Summary of Test Specifications for ancillary laboratories (principally for
marrows)
*Flow cytometry (see also detailed test specifications)
-Bone marrow aspirate (2-4 ml) is placed into a heparinized Vacutainer.
Cytogenetics (chromosome analysis)
-Bone marrow aspirate (1 ml) is placed into thawed cytogenetics media. A
heparinized (green top) Vacutainer can be used if there is no media available.
*Gene rearrangement (molecular oncology)
-Bone marrow aspirate (2.5 ml) is placed into an EDTA Vacutainer.
*Cultures
-For bacterial cultures fill 3 small isolator tubes (3-cc total) with bone marrow
aspirate.
-For viral cultures place 1-2 ml of bone marrow aspirate into a heparinized
Vacutainer. (Excluding Parvovirus)
*Parvovirus by PCR
-Place bone marrow aspirate (2.5 ml) into an EDTA Vacutainer.
-This test is sent to Magee Hospital.
*CMV by PCR
-Place bone marrow aspirates (1-5 ml) into ACD Vacutainer.
-Test is performed in virology lab.
Bone Marrow After-Hours
Procedures
UPMC Presbyterian Shadyside Special Hematology
Policy: BM 3.0
Subject: After Hours and Emergent Bone marrow Collection and Processing
Effective date: 1986
POLICY/PRINCIPLE
It is the policy of the Special Hematology/Bone marrow room to assure that bone
marrow specimens collected after hours or in emergent situations are properly collected
and yield the optimal quality and volume to enable the most accurate diagnosis.
SCOPE
Instructions for collection of bone marrow specimens for specific departments are listed
in the Medialab document BM 2.0 entitled Bone Marrow Collection Procedure , for
accessioning document Proc 21.0 entitled Bone Marrow Specimen Accessioning and
for grossing directions document Proc 31.0 entitled Bone Marrow Grossing and
Dictation.
RESPONSIBILITY
All personnel who assist on bone marrow collections.
PROCESS:
1. The Bone marrow technologist is available Monday through Friday between the
hours of 8:00 AM and 4:00 PM. (exclusive of weekends and all UPMC holidays)
to provide bedside assistance with bone marrow procedures. At all other times
assistance at UPMC PUH campus is not available. For assistance at UPMC
Shadyside, call (412) 623-6011. For assistance at UPMC CHP Lawrenceville,
call (412) 864-9877. Bone marrow assistance at UPMC Magee Women’s
Hospital is provided by the cytogenetic laboratory. For assistance call, (412) 6415558.
2. On weekends and holidays if an urgent request for bone marrow assistance
arises on UPMC PUH campus, inform hematopathologist on-call/CP resident oncall about the patient so they can inform clinician about alternate testing options
available.
3. CHP bone marrow specimens requiring immediate afterhours attention (e.g.
acute leukemia), the CHP ATL technologist will triage the sample for ancillary
tests, perform a quick stain of 2 aspirate smears, ship 1 stained aspirate slide, 1
peripheral blood smear and current CBC results with the rest of the bone marrow
to the CLB Flow Cytometry Laboratory, 9th floor, room 9032 and notify the oncall CLINICAL PATHOLOGY RESIDENT and hematopathologist.
The second stained aspirate smear will be placed in a folder in the CHP Heme
lab for the Heme/Onc clinician to review.
4. Routine bone marrow specimen processing:
Not available after 5:30PM Monday to Friday and Saturday after 12 noon. Bone
marrow aspirate and biopsy specimens that cannot be delivered in time to be
processed can be kept in the Hematology labs of SHY and CHP hospitals in the
room temperature and sent the next morning to the CLB Flow Cytometry
processing area.
 This procedure is also followed if Monday is a holiday.
 Outside bone marrow cases: Monday - Friday evenings all outside bone
marrow cases are delivered to the CLB Flow Cytometry specimen processing
area room 9032 and processed on the next working day by a specimen
processor.
5. EMERGENT bone marrow biopsies on weekends and holidays:
 Bone marrow specimens will be accessioned and most biopsies grossed in
until 12 noon on Saturdays by the Special Hematology staff.
 Note: On Saturdays, Histology needs to receive bone marrow biopsy
specimens before 12 noon in order to process it on the overnight processor
and be ready the next working day (Monday or Tuesday if Monday is a
holiday).
 If an EMERGENT specimen is received on Saturday (after 12:00PM), on
Sunday or on a UPMC holiday, the on-call hematopathologist must be
contacted to decide if the bone marrow biopsy qualifies for the emergent
processing.
 The EMERGENT bone marrow biopsy will be accessioned and grossed in by
the Clinical Pathology resident on-call using the following MediaLab
procedures:
- Proc 21.0: Bone Marrow Specimen Accessioning
- Proc 31.0: Bone Marrow Grossing and dictation


The CP resident on-call will deliver the grossed in bone marrow biopsy to the
Histology lab, CLB 2nd floor room 2018 and place it in the ‘Medspeed blue IN
bin’. The bone marrow biopsy will be processed by the Histology evening
staff and ready the next working day (Monday or Tuesday if Monday is a
holiday).
Note: Please refer to the Medialab policy HIST 113 entitled Weekend and
Holiday Procedures for the Histology information.
6. Flow Cytometry:
 If specimens cannot be delivered by 5:30 PM Monday through Thursday,
leave the specimen at room temperature at the UPMC SHY or CHP
Hematology lab. It will be sent to the Flow Cytometry lab the next working
day.
 If specimens cannot be delivered by 5:30 PM on Friday, or if there is a
specimen obtained before noon on Saturday, call the Flow Cytometry lab
between 8 AM and 1 PM on Saturday at (412) 864-6173 to inform them that a
specimen is being sent to the Flow Cytometry lab. Leave an Audix message
if the Flow lab is closed.
 Specimens from Saturday afternoon, Sunday, Thanksgiving, Christmas and
other holidays after 1 PM, should be held at room temperature and then sent




to the Flow Cytometry lab the following normal working day (Monday or
Tuesday if Monday is a holiday).
Only on holidays that fall on Monday: flow technologist is on call between 9-1
PM.
Any holiday that falls on a weekday: flow lab is usually closed. However, flow
lab is never closed 2 days in a row. Check with attending if major holiday is
on weekend.
In an emergency on all other Monday holidays before 1:00 PM, clinicians are
to page the CP resident on-call who will then contact the hematopathologist
on-call. All specimens received after 1PM are held until the next morning.
The Flow Cytometry technologist on call is then contacted by the
hematopathologist as needed (pager 6331, long range (412)565-9553).
7.
Cytogenetics:
 Monday through Thursday, specimens that cannot be received by the
Cytogenetics lab before 5:30 PM should be stored at room temperature
overnight. Specimens are sent to the Cytogenetics lab the next day.
 For specimens obtained Fridays that cannot be received by the Cytogenetics
lab by 5:30 PM, leave the specimen at room temperature in the Cytogenetics
bin in the CLB specimen processing area or SHY/CHP Hematology areas for
pick up on Saturday.
 Saturday/Sunday/Holiday specimens: Be sure that the specimen gets to the
CLB specimen processor. The SHY and CHP specimens will be delivered to
the Cytogenetics lab directly from SHY and CHP hematology. The CLB
specimen processor or SHY/CHP technologists will contact the Cytogenetics
lab by page at (412) 917-9458. Cytogenetic lab personnel arrange for the
courier pick up of these specimens. Alternatively, call (412) 641-6688 and
follow Audix instructions.
8.
Molecular Diagnostic studies:
 Specimens should get to the lab by 4 PM if at all possible. If other
arrangements need to be made or any questions answered, the attending oncall will be available at pager (412) 433-9591. They may be able to have
someone come in on Saturday.
 Specimens that have to be held over the weekend or holidays are held as
follows:
o DNA testing:
Keep the samples at room
temperature.
o RNA testing:
Refrigerate the samples at 4o C.
o DNA and RNA testing:
Refrigerate the samples at 4o C.
o Tissue samples:
Freeze the samples at -20o C.
 A molecular specimen drop off bin is located in the CLB-ATL specimen
processing area.
9.
The Flow Cytometry Lab, processing room is the central receiving area for bone
marrow specimens received from UPMC and non-UPMC affiliated hospitals. The
lab is open from 8:00 AM to 6:00 PM, Monday through Friday and from 8:00 AM
to 4:30 PM Saturday. During these hours the flow technologists/processors are
responsible for triaging the specimens they receive (except as noted in number
5). If they receive a marrow requiring emergency review after 5 p.m. or on the
weekend, they will contact hematopathologist/CP resident on-call.
 If a routine bone marrow specimen is delivered to the UPMC PUH Gross
Room, hold specimen to the next working day and either send with the courier or
hand deliver to CLB Flow Cytometry processing area.
Revised 03/2016
Lymph Node
Experience
Lymph Node Pathology Experience (~4 weeks)
Lymph Node Sign Out
A.
“On call” for processing of fresh lymph node biopsies.
NOTE: One of the lymph node assistants are available to help gross from 9-5:30/6 pm. The lymph node
assistant pager number is 412-958-7432. They will independently gross most specimens but may require help
either over the telephone with images that can be seen using our gross imaging “telepathology” or you may
need to help them in person in the CLB (Room 9032). If you get called during these hours, be sure to page the
lymph node assistant if they are not already in or on their way to the grossing area in the flow cytometry
laboratory (CLB 9032). After 5:30 pm and until 9 pm, the Hematopathology fellow or resident on an extended
day shift (see Hematopathology Schedule) can help. On occasion, one of the lymph node assistant should be
able to gross in lymph nodes or help out until 6:00 pm.
 Become familiar with detailed lymph node protocol, spleen protocol and consult procedures.
B.
Sign out of both fresh and consult lymph nodes and related material with staff. Be sure to meet
with hematopathologist on lymph node service to review organizational aspects of this rotation.
Become familiar with role of the lymph node assistant, use of hematopathology case worksheet,
established procedure for organization of sign-out materials, reviewing flow cytometry and
guidelines for dictating reports.
C.







D.
Checkpath (images, histories and explanations of faculty CME program for Hematopathology)
(PUH G315 and in Dr. Swerdlow’s coordinator’s office).
Teaching/conference sets of glass slides of marrows, lymph nodes, etc. (Dr. Swerdlow’s office).
Lymph node chapter in Sternberg.
Swerdlow, S.H., Campo, E., Harris, N.L., Jaffe, E., Pileri, S.A., Stein, H., Thiele, J., Vardiman, J.
(Eds.): WHO Classification of Tumours Pathology of Haematopoietic and Lymphoid Tumours,
IARC, Lyon, 2008.
Ioachim, HL Medeiros, LJ. Ioachim’s Lymph Node Pathology, 4th edition, 2009.
Jaffe ES, Harris NL, Vardiman J, Campo E, and Arber D. Hematopathology, 2010
Web-based resources.
Review results of ancillary studies procedures performed on lymph nodes you have reviewed
and read addenda that faculty issue.
APPENDIX I -SURGICAL PATHOLOGY MANUAL: LYMPH NODE PROTOCOL
Subject: The protocol is for lymph node or extranodal biopsies with suspected hematopoietic or lymphoid
disorders.
1.0
Principle
Diagnostic lymph node biopsies and other biopsies with suspected lymphoproliferative disorders should be
handled in a standard fashion to optimize histiologic sections and make appropriate ancillary studies
available.
2.0
Specimen
2.1
Criteria:
All tissues where lymphoma is suspected or documented in the patient history as well as all lymph node
biopsies in which the only specimen submitted for study is the nodal tissue, and if performed, a frozen
section has excluded metastatic carcinoma. Cases where post-transplant lymphoproliferative disorders are
suspected are not included unless requested by the Division of Transplant Pathology. Lymph node
excisions performed solely as non-lymphoma staging procedures are not included unless gross, touch
imprint or frozen section studies suggest a hematopoietic/lymphoid neoplasm. The protocol should be
performed under the supervision of a hematopathologist or designate if at all possible.
Emergent lymph nodes on weekends and holidays:
The AP resident should be paged who will determine the most appropriate resident on call to handle the
specimen. After hematopathologist’s approval, the resident on call will make the LN specimen Same Day
Rush Priority. The on-call resident will contact the histotechnologist on call (pager 12239) and take the LN
specimen to the Histology lab located in the CLB room 3018. The Histotechnologist on call will place the
LN specimen on the overnight processor so the specimen will be ready the next working day.
2.2
Fixation:
Fresh or saline moistened tissue. RPMI essential media is used to transport tissue. Formalin or any other
chemically fixed tissue cannot be processed using this protocol and will be handled according to general
cutting manual techniques. Specimens received in formalin in which lymphoma is suspected should have
at least one section post-fixed in B+ fixative.
2.3
Sample size:
Any size tissue can be processed.
3.0
Reagents, Supplies and Equipment
3.1
Reagents:
B+ Fixative
100% formalin
10% formalin
OCT
(Warning: Formalin is a suspected carcinogen. HANDLE WITH CAUTION. DO NOT INHALE. See
MSDS Binder.)
(Warning: B+ fixative contains zinc chloride and formaldehyde. HANDLE WITH CAUTION. DO NOT
INHALE. See MSDS Binder.)
3.2
Supplies:
Lymph Node Gross Dictation Sheet (Appendix E)
Log for freezer (Appendix C)
Liquid nitrogen
Cytocentrifuge cardboard
Slides (Regular and “+” slides)
RPMI essential media
Beam capsules
Marking pens
Tissue processing cassettes
Personal protective supplies
Gloves
Apron
Shield
Plastic freezer box to hold Beam Capsules
Saline solution for Molecular studies
Specimen bags
Sterile containers
Forms for Molecular Diagnostics (Appendix J)
Forms for Cytogenetics Lab (Appendix K)
3.3
Equipment:
Liquid Nitrogen tank
-80° degree freezer
Scalpel
Forceps
4.0
Calibration and Standardization
Not Applicable
5.0
Quality Control
5.1 All problems noted with specimen processing will be entered under the "Adverse Event" section for
each case in CoPath. (See Appendix G.)
6.0
Procedure
6.1
If a frozen section is requested, call the responsible surgical pathologist and resident. The first part of
the gross description should be filled in on the template. The specimen should be kept as intact as
possible and cut as illustrated and described in sections 6.7-6.10. If the frozen section shows
metastatic carcinoma, the case will be handled as per routine, in the surgical pathology division. If
metastatic carcinoma is not identified, continue with protocol. The cassette designation for the
resubmitted frozen section should be filled in on the gross description template—(FS).
NOTE : ALL HEMEPATH SPECIMENS ARE GROSSED IN THE FLOW CYTOMETRY LABORATORY –
CLB Room 9032
6.2 Place tissue in gauze soaked in RPMI in a sealed container labeled with patient name and surgical
number.
6.3 Page the hematopathology LN assistant first. If LN assistant does not answer, page the
hematopathology fellow or resident on call for lymph nodes (See schedule). If any problem, call the
Hematopathology Division Coordinator at 647-5191 and have her contact the Hematopathology resident or
fellow on call. If Coordinator does not answer, call the Hematopathology secretary 412-647-0382 with the
same instructions. If the LN assistant and trainee on call or on the LN service cannot be found, page the
faculty on the LN service or if necessary the faculty on call.
If no one answers, contact any of the hematopathology fellows or any other hematopathology faculty.
6.4
Specimens that arrive in the evening will be handled by the hematopathology fellow or resident on an
extended day shift who will follow this protocol as best they can. Material may be held in RPMI for flow
cytometry but this should only be done if there is enough tissue for 2 good histologic sections plus
enough for 3 snap frozen pieces. No material will go directly to the molecular laboratory. If the
following day is a workday and you are unfamiliar with this protocol, place the entire specimen in RPMI,
place in the refrigerator and notify hematopathology the following morning (See 6.3).
Emergent lymph nodes on weekends and holidays: After hematopathologist’s approval, the resident
on call, assigned by the Chief resident, will make the LN specimen Same Day Rush Priority . The
resident will contact the histotechnologist on call (pager 12239) and take the LN specimen to the
Histology lab; CLB-2nd Floor. The Histotechnologist on call will place the LN specimen on the overnight
processor so the specimen will be ready the next working day.
In the event of receiving a portion of tissue from a non-lymph node specimen for ancillary
studies from an organ specific bench:
a) A section of tissue is taken for Histology on specimens sent to us for ancillary studies.
When there is not enough tissue, the specimen will be entirely submitted for flow.
b) A block with a new name will be created in CoPath “HP” for (Hematopathology).
c) A section from the tissue taken by the technologist will be submitted to Histology in the
block named “HP”.
d) Comment will be entered in CoPath by the technologist for histology to send the H&E to
Hemepath. If it turns out not to be Hemepath’s case, this H&E will be forwarded to the
appropriate center of excellence.
e) The Technologist will make sure that block “HP” is assigned to the correct specimen part
in CoPath. If 1 cassette is needed from part 2, Example: Part 2, block HP, if more
cassessts are needed, Example: Part2, block HP1, HP2, HP3, etc. Gross description must
clearly reflect this.
6.5 Inform the lymph node service assistant or resident, fellow or, if necessary, the hematopathologist on
lymph node service that tissue has arrived in the Flow Cytometry Laboratory CLB Room 9032.
6.6 Observe tissue grossly and write down brief gross description on template. (Appendix D) Describe
size, color, and consistency.
6.7 Cut lymph node perpendicular to the long axis. Keep tissue moist at all times:
*
*
6.8 Cut a small paper thin slice, place on a cytocentrifuge preparation cardboard and make 2 fixed imprints
(done on regular slides) which can be stained immediately with H&E and 3-5 air dried imprints (done on “+”
slides) to be saved at the LN grossing station until the case is completed (for additional special studies, if
appropriate). Unused slides are filed in the slide file drawers. The code TP documents the test.
6.8.1 Look at the touch imprint to make a preliminary assessment of the lymph node. If
performing flow cytometric studies, check if any special studies should be performed (e.g., if the
cells appear blastic, an acute leukemia panel should be run) and about the size of the cells that
are of interest (small, large, mixed) and inform the flow technologist. If no one is present in the
flow lab write the request on the requisition and place it together with the specimen in the
refrigerator located at the flow lab CLB 9th floor- Room 9032 (See 6.3).
6.9 The central portion of the lymph node should be cut into 2-3 mm slices and if >2 cm in maximum
dimension, hemisected (sometimes it is easier to initially cut 5-6 mm slices and after brief fixation to slice in
half). Include the node capsule in the sections. Be sure to include any focal lesions. No pieces should be
larger than 1.5 x 2 cm.
6.9.1 Fix at least one section in 10% neutral buffered formalin. If tissue is very limited, formalin
fixation takes precedence over B+ fixation.
6.9.2 Each cassette has a unique designation (ACMB/DNA, BB+, C, etc). Be sure to use the
appropriate cassettes. PH White Rule out lymphoma cassettes will be labeled using the
cassette engraver with the surgical pathology number and a unique block designation
[A(CMB/DNA) OR AFS (for frozen section), BB+, C, etc.] by selecting PH White (R/O
Lymphoma). For needle core biopsies or tiny pieces of tissue, specimens should be marked
with eosin and wrapped in filter paper and put into mesh cassettes. Note in your gross
description if you feel the tissue may not survive processing.
6.10
Use end positions (*) for the following (unless focal lesions are present only in
this area or only in the midportion).
6.10.1 Culture, if appropriate, and if the surgeon has failed to do cultures (unless sterile, only
AFB and fungal cultures are generally meaningful).
6.10.2 Cell suspension immunophenotypic studies (flow lab 624-3746). Keep ½ to 1 cm3 fresh
and moist for this. Place in container with 50 ml RPMI media. Label and place in a biohazard
bag with a copy of the requisition with flow panel decided.
6.10.3 Snap freeze tissue 3+ blocks (approximately 7x4x3 mm) in cryovial capsules (2 without
OCT and 1 with OCT) labeled with the surgical pathology number in the liquid nitrogen tank in
flow lab. If a surgical pathology number is unavailable at the time, print the patient’s full name
and date on the tube. Snap capsules onto cryocane, dip into liquid nitrogen tank for a least 60
seconds. These are to be placed in the –80o C freezer (place in current capsule box) located in
the CLB room 9032 lymph node grossing area in the designated box and logged in on the log
sheet located on the freezer.
6.10.4 Submit a 7x7x5-mm piece to the Clinical Molecular Diagnostics Laboratory for possible
molecular diagnostic studies. Place tissue in a container with saline labeled with surgical
number and place in a self-sealing biohazard bag. Submit an adjacent piece for routine
processing labeled CMB/DNA to document the nature of piece sent for molecular studies.
Place a copy of the requisition and a filled out Molecular Diagnostics form in the side pouch of
the bag. Place a Molecular Diagnostics sticker on specimen bag. During working hours
(Monday-Friday 7am-3: 45pm) tube to station #370. After hours place in lymph node fridge next
to grossing bench.
6.10.4.1
After hours place specimen in the lymph node refrigerator next to the grossing station on
side door and send it the following day.
6.10.6 If there is a high suspicion of lymphoma and enough tissue after all of the above portions
are taken, place a 7x7x5 mm (or larger) fresh STERILE piece of tissue in RPMI to send to the
Cytogenetic Laboratory for chromosome (karyotype) analysis. Place a Cytogenetics sticker on
specimen bag.
6.10.6.1 The specimen can be tubed to station #417 (Magee
Womens Automated Testing Laboratory) at any time MondaySaturday (up until 1:00pm)
6.10.6.2 After 1:00pm on Saturday, place specimen in the lymph node refrigerator
next to the grossing station for it to be tubed to station #417 the following
Monday by the LN assistant.
6.11 Note:
6.11.1 A well-fixed section is the highest priority although almost no node is too small to preclude snap
freezing one piece.
6.11.2 Lymph nodes received in formalin can still be post-fixed in B+
6.12 Once the protocol is completed, the fixed portions are submitted to histology and the completed
gross description template dictated.
6.13
Summary of Lymph Node Protocol
6.13.1 Touch Imprints
6.13.1.1 Quick fix in alcohol and stain with H&E for immediate review
6.13.1.2 Air dry, place in box next to the grossing station.
6.13.2 Fresh tissue for special labs
6.13.2.1 Fresh piece in RPMI for flow lab (give to the flow tech)
6.13.2.2 Fresh piece in saline for molecular diagnostics (See 6.13.4.4)
6.13.2.3 Fresh piece in RPMI for Cytogenetics
6.13.2.4 Fresh piece to Microbiology if required.
6.13.3 Snap freeze 2 pieces of fresh tissue in beem capsules and 1 piece in Beem capsule in
OCT and store in box in -80 freezer located in the LN grossing area. See protocol for details.
6.13.4 Fixed tissue sections
6.13.4.1 If frozen section was performed, submit FS piece in cassette A in
formalin.
6.13.4.2 Cut thin and fix ≥ 1 sections in cassette BB+ after B+ fixative. Put
jar.
time on
6.13.4.3 Submit one section of tissue in cassette ACMB/DNA fixed in
formalin that is adjacent to the molecular diagnostics piece.
6.13.4.4 Submit the remainder of tissue in cassettes C, D, E, etc.
6.13.4.5 Use White colored cassettes to be engraved by selecting PH White (Rule out
lymphoma) under ‘Block Detail’ in the Histology section.
6.13.5
Comments
6.13.5.1 If during normal working hours the lymph node assistant/
hematopathology fellow/resident (staff) should be called to perform this protocol.
6.13.5.2 If very little tissue is present, good histologic sections and one snap frozen piece are
generally the highest priorities.
6.13.5.3 A gross dictation template should be used.
6.13.6 Diagram of Summary
B+ and formalin fixed sections


Snap freeze 3-5 pieces
Molecular Lab with
adjacent piece submitted
in fixative “CMB/DNA

If required
--Culture

Cytogenetics
Flow Laboratory
Touch Preps

7.0
Calculations
Not Applicable
8.0
Reporting Results / Normal Values
Not Applicable
9.0
Periodic Maintenance
Not Applicable
10.0
Procedural and QA Notes
Not Applicable
11.0
Limitations
Not Applicable
12.0
References

Fix and stain
Air dried & Save
Banks, PM Technical Aspects of Specimen Preparation and Introduction to Special Studies. In: Jaffe, ES
Surgical Pathology of the Lymph Nodes and Related Organs. pages 1-22, 1995, W.B. Saunders,
Philadelphia.
Leonard, D Diagnostic Molecular Pathology (Volume 41 in the series “Major Problems in Pathology”),
Saunders, 2003.
Revised 7/2004 LF
Revised 1/2010
Revised 3/2010 CF
Revised 10/2013 LF
How to handle very small specimens being submitted for histology*
1.
2.
Specimens should be marked with eosin and wrapped in filter paper and put into mesh
cassettes. Note in your gross description if you feel the tissue may not survive processing.
The histology lab will contact the responsible house-staff officer and faculty member
immediately if there is a failure to identify tissue in a cassette.
RECUTS OF SMALL PIECES OF TISSUE
Suggestions from Dr. Yousem when you are asking for recuts of very small pieces of tissue. It would be very
worthwhile to alert Histology that the fragments of tissue are small and care must be taken. Instructions in the
stain comment fields are helpful.
1. Tell the lab to "take sections right off the top", "do not face the block"- this alerts them not to aggressively
"face" the block
2. Tell the lab to take "serial sections"-- this way they do not lose sections between the ones obtained for your
stain requests
3. Ask for unstained slides in addition to the required ones-- this allows you to have extras should the stain
not work or tissue fall off the slide
4. If it is a very tough case, ask that an experienced technician handle the case- make this request in the
comment or call the lab
5. Cell blocks in cytology should always contain this type of request, in my opinion.
Pictorial Version of Lymph Node Protocol
(Double click on the link below for the PowerPoint Presentation)
Z:\Linda Koerbel\Fellow LN grossing presentation\Grossing Fresh Lymph
Nodes - LF SHS revision 12 09 updated 02-16-2012.ppt
Submitting Histology After Grossing
When we receive fresh tissue (in saline or RPMI): Submit the cassettes in formalin
filled container appropriately labeled “HISTOLOGY LAB” and they can either be tubed
to station #320 (Histology lab) or if after hours leave on LN grossing bench to be sent
the following day.
NOTE- PLEASE USE YOUR JUDGEMENT
Surgical Pathology Manual: Spleen Protocol
PROCEDURE:
1. Measure the spleen in three dimensions and weigh.
2. Section the spleen transversely at .5 to 1.0-cm intervals. *Photograph any lacerations and/or
surgical tears before transverse sectioning. To take a picture with Nikon digital grossing camera, make
sure all power is turned on as follows: turn on power switch on box next to the PC, turn on power button on
box at camera, and turn on power switches for both lights. ’Place specimen on camera base on table. In
Copath under PHS case no. using Accession Entry Edit or Image entry edit, click on Image gallery,
then click “Import from TWAIN”, and then click on “C” to capture the image.
3. The lymph node protocol for handling lymphomas should be followed in cases of suspected
lymphoma (staging, etc.) and other hematopoietic disorders.
4. Any hilar nodes or accessory spleen should be submitted separately.
5. Photograph one section of spleen.
DESCRIPTION:
1.
2.
3.
4.
Weight and dimensions.
Hilum: nature of vessels, presence of lymph nodes or accessory spleen.
Capsule: color, thickness, focal changes, adhesions, lacerations (location, length and depth).
Cut surfaces: color, consistency, malpighian corpuscles (size, color conspicuous), fibrous
trabeculae, nodules or masses, diffuse infiltration, red or white pulp disease.
SECTIONS:
1. If no gross abnormality is seen, and the spleen is taken out as an incidental splenectomy, submit
two to three random sections.
2. If the spleen is grossly lacerated, submit two to three random sections including the area of
laceration.
3. If it is a leukemia or lymphoma case, submit a minimum of five sections (B+ and formalin fixed),
including any distinct nodules. Several nodules should be submitted in cases of focal disease. At
least one section should include the capsule. Sections should be thin and no larger than 1.5 x 2.0
cm.
ANCILLARY STUDIES:
1. Make certain that if a hematopoietic/lymphoid neoplasm is suspected, tissue is processed for all the
potential ancillary studies described for lymph node biopsies.
Revised 10/2013
LYMPH NODE GROSS DICTATION –TEMPLATE
Dictation phone # 802-6706 Work type #9004 For multiple parts use other side>>>
CASE# PHS___: __________________
NAME: ______________________________
MEDICAL RECORD #___________________
Protocol to order in
histology- ‘Rolym’ (select
the ‘load’ box then ‘run
protocol’ button)
PLEASE DICTATE CLINICAL HISTORY AS STATED ON REQUISITION
The specimen is received [fresh in RPMI or formalin] labeled with the patient’s name, initials ___, MRN,
and [specimen site] ”___________________” It consists
of______________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Air dried touch preparations are performed, material is snap frozen (__ blocks), and sent for cell
suspension immunophenotypic studies (flow cytometry). A portion is sent to the molecular
diagnostics laboratory with an adjacent section submitted in cassette A (CMB/DNA). Additional
material is sent for cytogenetic studies. The [remainder or representative sections] of the [site
location] is (are) submitted in cassettes BB+ after B+ fixation and in blocks C - ______ after formalin
fixation.
Note: Do not use the B+ fixation if you only are submitting one block, formalin only.
(NOTE: IF a frozen section was submitted by another bench, submit in cassette AFS.) Make sure you
order ‘FRZ1’ in Stain Process for every frozen section block submitted
Write on sides of blocks: B+ fix on B+ fixed blocks
Checklist for specimens:
*Make sure all containers, slides, and frozen capsules
are labeled with the case # and patient’s name*
__Touch preps ---2 stained (H&E) on regular
slides to evaluate what type of flow panel to
order
__3 air dried slides on PLUS charge slides
for possible Cytogenetic FISH studies
___ Cassettes are ordered under ‘Block
Detail’ , then select PH White (R/O
Lymphoma) under engraver type
__Put the Date and Time on the formalin
and B+ fixative container
__Snap frozen- 2 capsules without OCT
compound (only if enough tissue available) ,
then 1 capsule with OCT
__Flow cytometry- container with RPMI
(found in refrigerator) w/ copy of requistion
NOTE- On call fellows/ residents: please put
flow specimen on top shelf of flow fridge
(located centrally in lab next to biochemical
hood) and put requisition with flow decision
on staining bench.
_Molecular Diagnostics- container with
Saline (found at grossing bench) fill out MDX
form and tube to station # 370 Hours MonFri 7am-345pm. After hours, put in LN fridge
to be sent following day.
__Cytogenetics- container with RPMI, fill out
form---- tube to station #417 anytime (but
after 1p Saturday-put in LN fridge).
Policy for solid tissue specimens sent to rule out lymphoma that overlaps with other Centers
of Excellence
In certain circumstances, specimens that fall into a non-Hematopathology Center of Excellence will either be
designated “rule out lymphoma” by the surgeon or have a potential lymphoma discovered either when a frozen
section is performed or when a fresh specimen is examined grossly. For example, a salivary gland may be
removed and a frozen section of a mass demonstrate a dense lymphoid proliferation without evidence of a
carcinoma.
If an intraoperative consultation is requested, the specimen should be handled by the surgical pathology
resident/fellow/pathologist on call at the hospital where the specimen has been removed.
In all cases, following completion of any required intraoperative consultation, both the
resident/fellow/pathologist on service for the Center of Excellence and the Hematopathology “lymph node”
resident/fellow/pathologist should be notified that the specimen is in the gross room. A joint decision
should be made at that time by both parties as to whom the primary pathologist should be based on factors
such as the likelihood of other pathology being present or any concern that a hematopathology protocol
would compromise any aspect of the pathologic examination.
In cases where the Center of Excellence is not located at UPMC-Presbyterian Hospital, the decision as to
whether the specimen should be handled in whole or in part by the Division of Hematopathology should be
made at the originating hospital. This should either be done by members of the Center of Excellence (for
example, if there is a GU specimen at UPMC-Shadyside) or after telephone agreement with the
appropriate AP-related COE pathologist. This will eliminate the possibility of specimens being sent first to
one hospital and then another. The resident/fellow/faculty on lymph node service should be consulted if
questions occur.
The Hematopathology “lymph node” resident/fellow/pathologist will be prepared to accept the responsibility for
processing the entire specimen, for taking a portion of the specimen for a hematopathology workup with
the remainder of the specimen grossed in by an anatomic pathology bench or functioning solely as a
consultant if special procedures are deemed unnecessary (for example, if suspicion for a lymphoma is low
and the tissue sample is very limited).
In cases where the initial triaging to either Hematopathology or one of the AP benches seems inappropriate
after sections are reviewed or ancillary studies become available, if agreeable to all parties, the primary
pathologist will be switched to the pathologist on the more appropriate service. This may involve a Center
of Excellence pathologist signing out a case not accessioned at their Center of Excellence, and ordering
stains that need to be sent by inter-hospital courier.
This model should be applied to all other Centers of Excellence where faculty, fellows or residents should act
to facilitate processing.
Instructions for Fresh Tissue Biopsies Received from Outside Institutions
[Revised 10/2013]
Sometimes tissue specimens from outside institutions are sent to our Flow Cytometry Laboratory
for cell suspension immunophenotypic studies or complete workup. In these cases, as long as
sufficient tissue is available, we try to do a complete lymph node protocol on them, except that
tissue is not sent to the molecular diagnostics or cytogenetics laboratory (except for cases from
UPMC-Shadyside, Magee Women’s or other complete case workups that also get material sent for
DNA extraction and, if appropriate, for cytogenetic studies). One must remember that if the tissue
has been sent here for flow cytometric studies, sufficient tissue must be retained specifically for
making a cell suspension. If the tissue submitted is very small, at a minimum, a touch imprint
should be performed, and if possible, a small portion snap frozen. On cytologic specimens, if
material has been retained at the referring institution, do NOT do touch preps unless there is a lot
of material (several good cores) and send the entire specimen to the flow cytometry laboratory.
Run the lymphoma protocol in CoPath but be sure to delete all the items that do not apply. You
don’t need a CMB/DNA block unless molecular is sent. If there are any questions on a given case,
please contact the pathologist covering lymph node biopsies.
Cases from CHP where we are not the primary pathologists traditionally are not sectioned (CHP
sections are reviewed prior to sign-out). Cases from other divisions for flow cytometry may have a
section taken if there is sufficient tissue and if acceptable to the division (to better know what we
are actually doing the flow cytometry on).
All fresh tissue cases from UPMC-Shadyside will arrive in the Flow Cytometry lab and accessioned
as UPMC- Presbyterian cases. All other cases from UPMC hospitals (and rare non-UPMC hospitals)
should be accessioned as UP consults UNLESS we have the entire specimen (with or without a
frozen section). If we have the entire specimen it should be accessioned as a UPMC- Presbyterian
case.
Fresh Case Lymph Nodes and Other Solid Tissues Sent to UPMC-Presbyterian for Flow Cytometric
Studies with a non-hematopathology Primary Pathologist [Revised 10/2013]
All non-PB, non-BM, non-fluid outside cases sent to the Division of Hematopathology for flow cytometry, that
are accessioned with a number that is solely being handled by the Division of Hematopathology, need not only
to have the flow cytometry signed out, but a complete report in the usual format. That report should include the
following components:

A History which is amplified from information that is entered when the case is accessioned and should
at least include the information on the requisition. It should also state: “Case received for flow
cytometric consultation.”

A Diagnosis - The diagnosis in cases that do not have a definitive malignant diagnosis can be "Flow
cytometric immunophenotypic studies are non-diagnostic (see comment)”. Other cases may get a
somewhat more definitive diagnosis, but, unless there is an actual disagreement, the diagnosis should
be consistent with what the primary pathologist is calling the case. Hence, the original pathologist on
almost all of these cases should be called. The diagnosis rendered can be a bit more vague than
usual, for example, a follicular lymphoma may be diagnosed without giving the grade.

A Comment - A comment that reiterates the diagnosis and states that the results must be correlated
with the material processed at the institution of origin should be included. It may refer to the
morphologic findings in the tissue processed or in the cytospin.

A Microscopic Description - The description can be of the morphologic findings in the tissue that is
processed or based on the cytospin, if there is nothing else. Or it can state that nothing was
processed for morphological studies.

A Billing code – If only H & E’s and flow are done, BC06. If additional workup or complete consultation
is performed after discussion with the referring pathologist, BC03, BC04, or BC5 (See “Copath and
dictation pointers” .for complete list of billing codes (BC))
In addition, it must be ascertained whether or not the primary pathologist is sending more material on the case
BEFORE the rest of the report is signed out. In general, some institutions do and some do not typically send
additional material. This should be indicated on the requisition but it is not always clear and not always
consistent.
On these "BC06" cases (BC14 for the VA), permission must be obtained to order immunostains, FISH,
molecular diagnostics, etc. If a full consult is requested on the requisition, IHC may be ordered. The primary
pathologist should be asked about doing FISH studies and molecular diagnostics, although if the case is from a
UPMC institution it should be acceptable. If a case is not from a UPMC institution, it is critical to obtain
permission to order anything other than the H&Es.
If you do IHC and flow was done, be sure to put in one of the Flow/IHC comments.
These cases also should have a synoptic if they are lymphomas.
Helpful Hints for Handling Consult Blocks
Ordering H&E slides on Consult Cases
With consult cases you must order the H&E as a recut (RHHE) because the only requests that come on
the Histology Special Request Log are special stains, Ipex, Hblanks, Iblanks and recuts. The slides
that come with the consult case are the original H&E. We cut from the blocks that are sent, therefore it
is a true recut.
When consult blocks are sent for special stains/immunos enter them in Client Server as follows:
-Under Stain/Process Edit/Entry:
-Select the Part that corresponds to Consult Block/s NOT Consult Slide/s
-Select Add Block and enter the block designation as the A, B, C – under block detail go the other
block number and put outside case #.
-Hint #1: An initial H&E is ordered automatically; however, it does not end up on the HISTO
worklog for some reason, so will never ever get it. You must re-order it as a recut (RHHE) to
actually get a slide.
-Hint #2: When you Add Stain/Process to a designated block, be careful to select the correct
block when ordering stains.
-Sometimes you get blank slides instead of a block; check to see what Part they are accessioned and enter a
designation just like a block, as above.
Sending Outside Blocks to Histology
All outside blocks are to be sent in yellow envelopes to Histology via the tube station # 320 with the PUH case
number, patient’s name, Pathologist’s name, and Resident’s or Fellow’s name written with a sharpie pen on
the envelope.
RULES FOR HISTOLOGY
All exceptions must be approved by
Dr. Yousem & Dr. Dhir
WHEN ACCESSIONING:
Pathology staff must be entered in the following order; Pathologist. (P) Fellow or Chief Resident. (R) If there is
no Fellow or Chief Resident on the case enter “none”. If there is no resident, this field can be left blank.
Initial H&E slides will be delivered to the listed pathologist in “reverse rank” order: 1) Resident, 2) Fellow/Chief,
3) Faculty.
New Bench Designations and Color Scheme; Please make sure the proper color cassette is used for
appropriate handling of specimen.
Hemepath – WHITE R/O Lymphoma
Rush Biopsies (PUH/SYS) - PEACH
Rush Neuropath (PUH) - GRAY
Cytology (PUH/SYS) - GREEN
ENT Routine (PUH) - PINK
GI Routine (PUH) - YELLOW
Muscle/Nerve Routine (PUH) - ORANGE
Neuropath Routine (PUH) - BLUE
Thoracic Routine (PUH) - TAN
Transplant Routine (PUH) - PURPLE
Autopsy (PUH) - WHITE
Autopsy Neuropath (PUH) - WHITE
Derm Rush (SYS) - GRAY
GU (SYS) - WHITE
Prostate Routine (SYS) - PINK
Skins Rush (SYS) - BLUE
Bone/Soft Tissue (SYS) - GREEN
STAT cut off times: The cut off time for receiving stats in the histology lab is 11: 00AM. No exceptions, unless
approved by Dr. Yousem and Dr. Dhir.
When accessioning Children’s Hospital bone marrows; they must be accessioned under pediatric bone
marrows, or they will be sent to the Hemepath lab, along with the other bone marrows. There will be no
exceptions.
WHEN ORDERING:
RE-CUTS – Must be ordered under RHHE, and the correct number in the count field. If levels are needed, this
must be entered in the stain comment field when ordering the re-cuts. The cut off time for ordering re-cuts is
1:00PM to be delivered same day by the 5:30 pm courier run. Anything after 1:00PM that day will be cut and
sent the following morning by the 8:30 am courier run. There will be no exceptions unless approved by Dr.
Yousem & Dr. Dhir.
SPECIAL STAINS – Must be ordered with the correct special stain code so there is no delay. Please
remember and take into consideration that some special stains take 2 or 3 DAYS to complete. The cut off time
for ordering Histo stains is 10:00AM and will be delivered on the 2:30PM courier run that day. Anything
ordered after 10:00AM will be stained the following day and delivered on the 8:30 AM courier run the following
day. The only special stains performed on weekends are the Stat Grocott, AFB, and Gram. There will be no
exceptions unless approved by Dr. Yousem or Dr. Dhir.
IMMUNOPEROXIDASE ANTIBODIES – Must be ordered with the correct antibody code so there is no delay.
Most Immunoperoxidase antibodies done in the clinical lab have the prefix A; please make sure the correct
antibody is ordered. Stains ordered before 10:00AM should come out the same day. Stains ordered after
10:00AM should come out by the 8:30am courier the following day.
When ordering special stains, immunos, etc. on blocks that are at Shadyside, order under Shadyside and
put a comment in the stain comment field saying where you want the slides sent.
REPROCESSING TISSUE:
Histology technicians are no longer permitted to decide if a tissue needs reprocessing. The
pathologist reading the case can only make that decision. Histology must send out a suboptimal slide,
which will be highlighted in green. The pathologist needs to determine if the tissue needs
reprocessing. The pathologist must call Histology and give permission to reprocess. A better H&E
will be sent the following morning.
ORDERING BLANKS FOR INSITU:
If the blanks are ordered before 11:00 AM will be sent to ISH on the 11:30AM courier run. Anything ordered
after 11:00AM will be delivered to the ISH lab on the 9:30AM courier run.
WHEN HISTOLOGY SENDS OUT SLIDES:
All lymph node and all bone marrow slides will be sent to the Hemepath lab.
All Transplant H&E slides will be sent to the case pathologist.
All Neuropath H&E slides, including autopsies, will be sent to the case pathologist.
All Transplant TB slides ordered will go to the case pathologist. All non-transplant TB slides will go to the
resident on the case entered in the comment field.
All EM kidney biopsy slides will be sent to the case pathologist.
E slides will go to Cytology. All recuts, special stains, and immunoperoxidase stains will be sent to the hospital
as specified in the stain comment field when ordered.
All dental slides will go to the Dental department.
All recuts, special stains, and immunoperoxidase stains will be sent to the doctor ordering them. The doctors
must enter in the stain comment field when ordering, the hospital where that doctor will be located to receive
their slides.
Comments override everything: All slides will be sent to the doctor and hospital specified in the stain comment
field.
For all blocks that need corrections, the appropriate department or person will be notified and they must come to the
Histology lab and make the corrections. Histology will no longer be responsible for making changes to the
cassettes. In addition, a specimen misidentification form must be filled out in histology.
Revised 10/2013
GENERAL FORMATTING REQUIREMENTS
FONT TYPE AND SIZE:

All reports are typed in Arial font, size 9.
GROSS DESCRIPTION
 The gross description is typed in sentence style, beginning at the left margin, in paragraph format.
 The patient’s initials are typed in all CAPS (i.e. The specimen is received in formalin labeled with the
patient’s name and initials, MSP.)
 The label of the specimen is typed within quotation marks (i.e. The specimen is labeled “right upper
lobe lung” and consists….).
 When multiple specimen parts are received a new paragraph is started for each part. (i.e. Part 1, Part
2, etc.), using Arabic numerals.
 When multiple specimen parts are received each part’s gross description must include the patient's
initials. (i.e. Part 1 is received labeled with the patient’s name and initials, MSP….. Part 2 is received
labeled with the patient’s name and initials, MSP.)
 For gross specimens with a cassette listing, a period follows the last submitted description only (see
example below).
EXAMPLE: Gross description for a one-part specimen
Gross Description
The specimen is received in formalin labeled with the patient’s name, initials MSP and “rectal biopsy”. The
specimen consists of an un-oriented, irregular, soft, tan, tissue fragment measuring 0.2 x 0.1 x 0.1 cm. The
specimen is entirely submitted in a cassette labeled A.
VGD/vat
EXAMPLE: Gross description for multiple-part specimens
Gross Description
The specimen is received in formalin in two parts.
Part 1 is labeled with the patient's name, initials MSP and “rectal biopsy”. It consists of an unoriented,
irregular, soft, tan, tissue fragment measuring 0.2 x 0.1 x 0.1 cm. The specimen is entirely submitted in a
cassette labeled 1A.
Part 2 is labeled with the patient's name, initials MSP and “antrum”. It consists of an unoriented, irregular, soft,
tan, tissue fragment measuring 0.2 x 0.1 x 0.1 cm. The specimen is entirely submitted in a cassette labeled
2A.
VGD/vat
EXAMPLE: Gross description with cassette listing
Note: When a specimen part is submitted in several blocks, these are indicated by a cassette listing at the
end of the gross description for that part. It is typed flush with the left margin (in the following order: part
number, letter designation, a space, a dash, a space, description of tissue in block). A period follows the last
submitted description only. The cassette listing is formatted as follows:
The specimen is submitted as follows:
1A – right upper lobe lung
1B – nodule 20 cm from resection margin
1C – stapled resection margin
1D – lung parenchyma
1E – remainder of tissue
Gross Description
The specimen is received in buffered formalin labeled with the patient’s name, initials MSP and “skin biopsy”.
The specimen consists of an un-oriented, irregular soft tan tissue fragment measuring 0.2 x 0.1 x 0.1 cm. The
following sections are submitted:
1A – tips
1B – ends
VGD/vat
EXAMPLE: Gross description for bone marrow biopsy
Gross Description
Received are an aspirate (part 1), biopsy, flow cytometry, cytogenetics and VNTR.
Part 2, bone marrow biopsy, is received in B5 fixative, labeled with the patient's name (MSP) and site. It
consists of a single core of tan, cancellous bone measuring 0.8 x 0.2 cm. The specimen is totally submitted to
histology for decalcification in block A.
VGD/vat
EXAMPLE: Consult material description (congross or cons) (may include a gross description)
Consult Material Description
Received for consultation from John Doe, M.D., are eleven (11) consult slides and nine (9) consult slides
labeled S05-192; one (1) consult slide labeled S05-3303 and one (1) consult slide labeled S05-6039 from
Memorial Hospital, Pathology Department, 9888 Generic Avenue, Big City, PA 12345, along with an
accompanying letter, surgical and cytopathology reports.
VGD/vat
EXAMPLE: Bone marrow biopsy clinical history (preop)
Clinical History
The patient is a 36-year-old male with a history of acute myelogenous leukemia, diagnosed in 04/2003
(PHB03-123456). A bone marrow performed on 02/200 (PHB05-111111) demonstrated 10% blasts. He is
currently day 33 status post allogeneic peripheral blood stem cell transplant. The bone marrow is for
evaluation of engraftment. Medications: Cycloporin, Diflucan, Acyclovir, Synthroid, Protonix and Magnesium.
VGD/vat
EXAMPLE: Consultation case, one accession number (y and preop)
Clinical History
The patient is a 70-year-old male.
OSS S05-192, 1/7/2005, MEMORIAL HOSPITAL
PRE-OP DIAGNOSIS:
None given.
POST-OP DIAGNOSIS:
None given.
PROCEDURE:
Fine Needle Aspiration right neck.
VGD/vat
EXAMPLE: Consultation case, multiple accession numbers (y and preop)
Clinical History
The patient is a 70-year-old male.
OSS-S05-3303, 04/14/2005, MEMORIAL HOSPITAL
PRE-OP DIAGNOSIS:
Left vocal cord lesion.
POST-OP DIAGNOSIS:
None given.
PROCEDURE:
Left vocal cord stripping.
OSS-05-6039, 07/07/2005, MEMORIAL HOSPITAL
PRE-OP DIAGNOSIS:
None given.
POST-OP DIAGNOSIS:
None given.
PROCEDURE:
Left vocal cord biopsy.
VGD/vat
EXAMPLE: All other surgical clinical histories (preop)
Clinical History
Abdominal pain.
PRE-OP DIAGNOSIS:
Abdominal pain.
POST-OP DIAGNOSIS:
Same.
PROCEDURE:
Rectal biopsy.
VGD/vat
GROSS ONLY SPECIMEN REPORTS
 The clinical history and gross description are typed as described above in the gross description
explanation.
 In the microscopic description field type: “No sections are submitted” or “None”.
 In the final diagnosis field type (in all CAPS): The specimen line, return and type the dictated final
diagnosis followed by the phrase, “gross diagnosis only; see comment” within parenthesis in lower case
letters (see example below).
 In the diagnosis comment field type the quick text code, gross and click on the running man icon to
insert the standard quick text template regarding gross only specimens and further testing. Go to the
pound (#) sign using the keystroke combination [ALT+F] and type in the specimen designation.
INTRAOPERATIVE CONSULTATION
 The intraoperative consultation text field is typed in ALL CAPS (similar to the final diagnosis section).
The only exceptions are: 1) the type of intraoperative consultation is typed in parentheses in
lowercase letters (for example: frozen section, gross diagnosis/examination only, touch prep) and 2)
the names of intraoperative staff member(s) performing the intraoperative consultation are entered
within parentheses at the end of the last line of the intraoperative consultation before the period (first
initial of first name in caps and full last name with initial caps and lowercase letters - in the following
order: staff pathologist/fellow/resident/PA including the title, M.D. when applicable) (see examples
below).
EXAMPLE: Single-part intraoperative consultation
Intraoperative Consultation
FS:
LUNG, LEFT UPPER LOBE, LOBECTOMY (frozen section) –
EXAMPLE: Intraoperative consultation with single-line diagnosis
FS:
A. BENIGN (T. Pathologist, M.D).
EXAMPLE: Intraoperative consultation with multiple diagnoses
FS:
A. BENIGN.
B. NO TUMOR SEEN (T. Pathologist, M.D. /C. Resident, M.D./A. Pa).
VGD/vat
EXAMPLE: Intraoperative consultation for multiple parts with multiple diagnoses
1AFS: LUNG, LEFT UPPER LOBE, LOBECTOMY (frozen section) –
A. MALIGNANT.
B. SMALL CELL CARCINOMA (T. Pathologist, M.D).
2ATP: LUNG, LEFT MIDDLE LOBE, LOBECTOMY (touch prep) –
A. MALIGNANT (T. Pathologist, M.D.).
3AGD: LUNG, LEFT MIDDLE LOBE, LOBECTOMY (gross diagnosis) –
A.
VGD/vat
BENIGN (T. Pathologist, M.D.).
EXAMPLE: Intraoperative consultation for one part with multiple frozen sections/touch preps
performed on different blocks
1AFS: SUPRAGLOTTIC MASS, LEFT, LATERAL, MEDIAL AND DEEP MARGINS (frozen section) –
A. MALIGNANT.
B. SQUAMOUS CELL CARCINOMA.
C. TUMOR PRESENT AT LATERAL MARGIN. MEDIAL AND DEEP MARGINS FREE OF TUMOR (T.
Pathologist, M.D./C. Resident, M.D.).
1BFS: SUPRAGLOTTIC MASS, LEFT, INFERIOR SHAVE MARGIN (frozen section) –
A. MALIGNANT.
C. TUMOR PRESENT AT THE MARGIN (T. Pathologist, M.D./C. Resident, M.D.).
1CFS: SUPRAGLOTTIC MASS, ANTERIOR SHAVE MARGIN (frozen section) –
A. MALIGNANT.
C. TUMOR EXTENDS VERY CLOSE IF NOT TO THE CAUTERIZED MARGIN (T. Pathologist,
M.D./C. Resident, M.D.).
VGD/vat
FINAL DIAGNOSIS
 The Final Diagnosis is typed in ALL CAPS and bold type. The exception: Any text placed within
parentheses that is non-diagnostic {i.e. (see comment)} is in lowercase bold type.
 The specimen line identifies the specimen, identifies the location of the specimen, and indicates the
procedure performed to remove the specimen and is aligned with the left margin. Following the type of
excision, type a space, a dash and then return.
 Each diagnosis ends in a period.
 A single diagnosis is aligned flush with the left margin and not indented.
 For multiple diagnoses, each diagnosis is given a letter designation (A, B, C, etc.).
 For multiple parts with one or more diagnoses, each part is labeled as PART # and followed by a colon
mark and a single space and the specimen line (i.e. PART 1: LUNG…). Each diagnosis is given a
letter designation (A, B, C, etc.), with the exception of a diagnosis with only one line. The letter
designation is aligned with the beginning of the specimen header in a hanging indent, (created using
the keystroke combination [CTRL+M]), followed by a period and a space, and then the diagnosis.
Note: When the hanging indent is created, hitting return at the end of the line A diagnosis will create
the appropriate indent for the remaining diagnosis lines.
 A blank line is inserted between parts.
 For consult diagnoses, place the outside slide number and the accession date of the outside slide
number in parenthesis next to the diagnosis specimen line.
 Expand abbreviations in the final diagnosis field. Example: If the dictator says CIN 1 type CERVICAL
INTRAEPITHELIAL NEOPLASIA 1 (CIN 1).
EXAMPLE: Final diagnosis heading - specimen part type, location of specimen, procedure performed
Final Diagnosis
LUNG, LEFT UPPER LOBE, LOBECTOMY –
EXAMPLE: Final diagnosis for one part with one diagnostic line
Final Diagnosis
LUNG, LEFT UPPER LOBE, LOBECTOMY –
BENIGN.
VGD/vat
EXAMPLE: One part, multiple diagnosis lines
Final Diagnosis
SOFT TISSUE KNEE MASS, RIGHT, EXCISION –
A. SKIN AND SUBCUTANEOUS TISSUE WITH FIBROUS-WALLED CYST WITH FOCAL RUPTURE,
B. SYNOVIAL CELL PROLIFERATION AND RARE NON-VIABLE BONY SPICULES OF
GANGLION/SYNOVIAL CYST, 11.5 X 3.8 CM (see comment).
C. NEGATIVE FOR MALIGNANCY.
VGD/vat
EXAMPLE: Multiple parts, one or more diagnosis lines
Final Diagnosis
PART 1: GALLBLADDER, CHOLECYSTECTOMY –
CHOLELITHIASIS AND MILD CHRONIC CHOLECYSTITIS.
PART 2: LIVER, RANDOM NEEDLE BIOPSY –
A. NON-CIRRHOTIC LIVER TISSUE WITH MICROVESICULAR AND MACROVESICULAR
STEATOSIS INVOLVING 30% OF THE HEPATOCYTES.
B. MILD NONSPECIFIC PORTAL CHRONIC INFLAMMATION (see microscopic description).
VGD/vat
EXAMPLE: Bone marrow biopsy final
Final Diagnosis
PART 1: PERIPHERAL BLOOD –
WITHIN NORMAL LIMITS.
PARTS 2
AND 3: BONE MARROW, BIOPSY AND ASPIRATE –
TRILINEAGE HEMATOPOIESIS WITH FOCI OF LYMPHOCYTOSIS INCLUDING LYMPHOID
AGGREGATES (see comment).
VGD/vat
EXAMPLE: Consultation diagnosis, one part, one accession number
Final Diagnosis
RIGHT AND LEFT OVARY, BILATERAL SALPINGO-OOPHORECTOMY (OSS S05-6612, 06/14/05) –
A. POORLY-DIFFERENTIATED INTRACYSTIC CARCINOMA WITH FEATURES OF SEROUS AND
ENDOMETRIOID CARCINOMA.
B. ADENOCARCINOMA APPEARS TO BE INTRACYSTIC WITHOUT EVIDENCE OF OVARIAN
SURFACE INVOLVEMENT ON PROVIDED SLIDES.
C. LYMPHOVASCULAR INVASION IS NOT IDENTIFIED.
D. LEFT FALLOPIAN TUBE, HISTOLOGICALLY UNREMARKABLE.
E. RIGHT OVARY AND RIGHT FALLOPIAN TUBE WITH PHYSIOLOGIC CHANGES.
F. DEFINITE ENDOMETRIOSIS IS NOT IDENTIFIED.
VGD/vat
EXAMPLE: Consultation diagnosis, multiple parts one accession number
Final Diagnosis
PART 1: ENDOCERVIX, CURETTINGS (OSS S05-1191, 07/07/05) –
ECTOCERVICAL AND ENDOCERVICAL TISSUE FRAGMENTS WITH NO SIGNIFICANT
PATHOLOGIC ABNORMALITY.
PART 2: ENDOMETRIAL CURETTINGS (OSS S05-1191, 07/07/05) –
ATYPICAL COMPLEX HYPERPLASIA IN A BACKGROUND OF SECRETORY PATTERN
ENDOMETRIUM WITH TUBAL AND CLEAR CELL METAPLASIA.
VAT/vat
EXAMPLE: Consultation diagnosis, multiple parts, multiple accession numbers
Final Diagnosis
PART 1: FINE NEEDLE ASPIRATION OF RIGHT NECK (OSS S05-192, 01/07/05) –
A. SATISFACTORY FOR INTERPRETATION.
B. NEGATIVE FOR MALIGNANT CELLS.
C. FRAGMENTS OF FIBROADIPOSE TISSUE.
PART 2: VOCAL CORD, LEFT, STRIPPING (OSS S05-3303, 04/14/05) –
KERATOSIS WITH MILD DYSPLASIA.
PART 3: VOCAL CORD, LEFT, BIOPSY (OSS S05-6039, 07/07/05) –
HYPERPLASTIC, CHRONICALLY INFLAMED SQUAMOUS MUCOSA.
VGD/vat
DIAGNOSIS COMMENT
 The diagnosis comment field is typed in sentence style in bold type, aligned with the left margin, in
paragraph format and may contain quick text or free text transcription.
EXAMPLE: Diagnostic comment
Diagnosis Comment
The histologic features seen in this material are consistent with quiescent ulcerative colitis. No dysplasia is
seen.
VGD/vat
CLINICAL HISTORY





In the clinical history field, standard quick text templates are used. Type the quick text preop for bone
marrows, consultations and all other surgical cases) and click on the running man icon to insert the
standard quick text template for the patient's clinical history. Go to the pound (#) signs using the
keystroke combination [ALT+F] and type in the dictated information.
The clinical history is typed sentence style (initial uppercase, remainder lowercase; see examples
below).
The patient’s age is typed with hyphens (i.e. The patient is a 24-year-old female).
The first word in the pre-op, post-op and procedure are capitalized and each line ends with a period
(see examples below).
Consultation cases include the outside slide number (OSS), outside slide accession date and the name
of the hospital requesting the consult between the clinical history line and the preoperative diagnosis
line in all capital letters and in bold typeface.
SYNOPTICS




A synoptic should be added to all bone marrow and solid tissue reports when a
hematopathologic/lymphoid neoplasm is being diagnosed. Currently on the bone marrows, these are
being added on first-time diagnoses only, although they do not need to be limited to those cases.
Instructions for the use of synoptics are available online. The CoPath user guide is posted on the
CoPathPlus website http://copath.upmc.com under the link for CoPathPlus Training Resources. The
Synoptic Data Entry and Reporting Chapter is Chapter 24.
A hard copy is available in rooms G315 and G323.
There are currently four (4) synoptics used in Hematopathology.
o Bone Marrow/Peripheral Blood Hematopoietic/Lymphoid Disorders Synoptic
o Gastrointestinal Lymphoma Resection Synoptic
o Hodgkin Lymphoma Biopsy/Staging Synoptic
o Non-Hodgkin’s Lymphoma Biopsy/Resection Synoptic
OTHER


Never use tabs.
Do not change FONT or center justify header in IHC table.
LYMPH NODE/SOLID TISSUE ORGANIZATION OF SIGNOUT MATERIAL
(SLIDES, BLOCKS, PAPERWORK)
1.0
Principle
1.1
2.0
All material, whether in-house or consult, received fresh or fixed (glass slides and/or blocks)
must be kept in an organized fashion with detailed records to facilitate efficient and accurate
functioning of lymph node/solid tissue hematopathology sign out service.
2.1
Specimens include all cases designated for hematopathology lymph node/solid
tissue service.
3.0
5.0
Reagents, Supplies and Equipment
3.1
Reagents
Not Applicable
3.2
Supplies
Hematopathology Case Worksheets
3.3
Equipment
Computer with Microsoft Office
4.0
Calibration and Standardization
Not applicable
Quality Control
5.1
All problems noted in terms of special handling, transcription or histology will be entered under
the “Adverse Event” section for each case in CoPath.
(See Appendix G - Adverse Event Recording)
6.0
Procedure
6.1
6.1.1
6.2
Throughout the day, all material for the lymph node service is brought into the lymph node sign
out room (G323) to be distributed with the cases.
If formalin fixed H & E stained slides from tissue grossed and submitted the day before
are not received by 4:00PM, follow up with a call to histology laboratory to determine
when the slides will be available (extension 647-7660).
Whenever slides are received, place on a tray with all other slides on the case together with all
paperwork and place on the microscope table.
6.2.1
If a Hematopathology Case Worksheet (Appendix B) already exists because the case
was handled in the gross room or the sheet was filled out when the consult was
accessioned/received, record which slides were received.
6.2.2
If a case does not already have a Hematopathology Case Worksheet, print one out
in Copath under the “Heme Worksheet” function.
6.2.3
Determine if any slides that should be present are missing by one of the following
methods:
6.2.3.1 Check gross description and current time. Rush formalin fixed and B+ fixed H&E
stains come out by the next day after submission. PAS should be out during the
afternoon on the same day.
6.2.3.2 Check the Hematopathology Case Worksheet for date/time stains were ordered.
Assuming the block is in histology, immunostains ordered before 9AM should be out late
on the same day (does not always happen) and those ordered by 6PM should be out
early the following day. In situ hybridization stains are typically expected in 2 days.
6.2.3.3 Print out the "CoPath Accession Log with stain information by specimen"
(Appendix H) after ordering the stains for the case. Check pending stains noting if all
verified stains have been received. (If not, call histology/immunohistology laboratory ext
7-7663) and if all unverified stains are not overdue (See 6.3.3.1 and 6.3.3.2 for expected
turn-around times and follow-up instructions).
6.2.3.3.1 Directions for CoPath called: “Accession Log with Information by Specimen”
1.
2.
3.
4.
Log onto CoPath.
Click on FILE in the menu bar.
Choose BROWSE ITEMS.
Under the Browse Items list, find the report "Accession Log w/Stain Info by
Specimen"
5. Click and drag the “Accession Log w/Stain Info by Specimen” report into your
menu on the left.
6. Double click on it to open the report.
7. The next time you log on, you will be able to directly access the report from
your menu list.
6.2.3.3.2 Directions for bringing up specific "Accession Log w/Stain Information" report:
1. Under Data Field, highlight "Specimen."
2. Choose Individual Items as selection method and type the specimen number
in the "Select a Specimen" Box.
3. Click OK.
4. Under Data Field, for "Retrieval Flag","Stain/Process" and "Request Class",
choose All Values as Selection Method.
5. Click OK and report will appear.
6.2.3.4 Attach copy of print out to Hematopathology Case Worksheet, with notation of
any follow-up performed.
All cases (slides, paperwork, folder) will be kept in one of the following shelves:
 Pending flow (inhouse or consult fresh tissue)
 Pending IHC cases (keep separated whether out today or the next day)
 Pending receipt of requested outside blocks/blanks/slides (Go through at least
every other day.)
 Pending H&E’s ONLY
 Pending Molecular and Cytogenetic studies
 Dictated, to Proof-read
 Signed out cases, pending Immunostains/ISH/ MDX/ Cytogenetics for addendums
Hematopathology Case Worksheet
PHS13-
PATIENT:
Blocks in Histology
Blocks sent down to histology
Blanks sent down to histology
Date/Time
Date/Time
Requested Date:
Blocks
Blanks
Other
Contact:
ROUTINE STAINS/BLANKS
Stain
H&E
PAS
Grocott
AFB
Blanks (#
Congo Red
Steiner
Code
)
IMMUNOSTAINS
Requested Ordered Received
Comments
Requested Ordered Received
Comments
HPAS
HGRO
HAFT
HBNKNC
HCNR
HSTNC
* = run stain process group
Stain
Small B-Cell Panel
CD3, 20,5,10,43
BCL-2,BCL-6,cycD1
Code
SBCP*
MALT Eval
anti-kappa, anti-lambda
CD20, BCL-2, CD43, CD5
BCL-6, CD10, cyclin D1, CD3
AMALTe*
DLBCL Eval
CD20, BCL-6, MUM-1
CD3, BCL-2, CD10
Cyclin D1, CD5, MYC, Ki-67
ADLBCL*
Cytoplasmic Ig-IHC
anti-kappa, anti-lambda
ACIG*
Cytoplasmic Ig-ISH
Kappa, Lambda, MRNA
ICIG*
Myeloma
Kappa BM, Lambda BM
CD138
AMyel*
Double k/lambda
IKPLM *
AIGH*
Ig Heavy Chains
anti-IgG,IgA, IgM, IgD
Anti-IgA
Anti-IgD
Anti-IgG
Anti-IgG4
Anti-IgM
CD20/L26
CD22
CD79a
PAX 5
CD21
CD23
AIGA
AIGD
AIGG
AIGG4
AIGM
AL26
ACD22
ACD79
APAX5
ACD21
ACD23
CD138
CD138
UPMC
Block(s)
RHHE
Block(s)
Page 1 of 4
Hematopathology Case Worksheet
J chain
BCL2
BCL2 E17
MYC
BCL6
CD10
IRF4/MUM-1
Cyclin D1
SOX-11
P27
LEF-1/TCF-1
Annexin A1
Mini-ALL
AJ
ABCL2
ABCL2E17
c-MYC
ABCL6
ACD10
AMUM1
ACYCLD1
SOX11
AP27
LEF-1
AANNEX
AAllm*
TdT, CD34
TdT
CD45/LCA
Hodgkin's Panel
CD3, 20, 15, 30
EMA, LCA
HL expanded
ATDT
ALCA
AHODPP*
AHL*
CD20, CD3, CD45/LCA,
CD30/Ber H2, CD15/Leu M1,
PAX 5, MUM-1,OCT-2, Bob.1, EMA
OCT-2/Bob.1
HL, extras
AOCT*
AHLe*
PAX5, MUM-1, OCT-2
Bob.1
CD15/Leu M1
CD30/Ber H2
EMA
ALCL
ALEUM1
ACD30
AEMA
AALCL*
ALK-1, Clusterin
Alk-1
Clusterin
Pan T-Cell/Basic subset
AALK1
ACLUST
APANT*
CD2, CD3, CD4, CD5
CD7, CD8
T-cell subsets other
ATCSS*
Beta-F1, CD57, CD25, Granzyme B,
CD56, TIA1, PD-1, CXCL 13
NK lymphoma
ANKL*
CD20/L26, CD2, CD3, CD5
CD7, Beta-F1, CD56, TIA1
Granzyme B
EBV-ISH (EBER)
CD1a
CD2
CD3
CD4
CD5
CD7
CD8
UPMC
ACD1a
ACD2
ACD3
ACD4
ACD5
ACD7
ACD8
Page 2 of 4
CD43/Leu 22
CD279/PD-1
CXCL13
Beta-F1
Gamma TCR
CD56
CD57/Leu 7
TIA1
Granzyme B.
CD25
Myeloblast eval
MPO, Lyso, Neut elast
CD117, CD34, TdT
Myeloblast-limited
MPO, CD117, CD34, TdT
ACD43
PD1
ACXCL13
ABF1
Mini-Myeloblasts
CD117, CD34
AMyBm*
BM Lineage
CD68/PGM-1, MPO, CD34
Glycophorin A,Factor VIIIRA
ABML*
CD68/PGM-1
CD123
TCL-1
Myeloperoxidase
Lysozyme
CD14
CD163
CD33
Neut. Elast
CD117
Tryptase
CD34
Glycophorin A
Factor VIIIRA
CD61
Ki-67/MIB-1
P53
AE1/AE3
Cam 5.2
Pankeratin
S100/S100a
CD207 / Langerin
ACD68
CD123
EBV-ISH (EBER)
EBV-LMP
Parvovirus
CMV
HHV8
H.Pylori
Bartonella (CSD)
Treponema
Herpes Simplex 1/2
UPMC
ACD56
ALEU7
ATIA
AGRANZ
ACD25
AMyBe*
AMyBL*
TCL-1A
AMPO
ALYSO
CD14
CD163
ACD33
ANE
ACKIT
ATRYP
ACD34
AGLYP
AVW F
ACD61B
AKi67
AP53
AAE13
ACAM
APANKR
AS100D
LANG
IEBER *
AEBV
APARVO
ACMV
AHHV8
HPYL
BHENS
ATREP
AHSV12
MOLECULAR
DNA/RNA (Already Stored)
Frozen
Blank Slides Available
TEST
Order blanks - See Page One
Req'd Ord'd Tissue/Slides Sent(date/time) Comments
Ig heavy chain and light chain gene rearrangment, PCR
T-cell receptor gamma chain rearrangment, PCR
T-cell receptor beta chain gene rearrangment, PCR
JAK2 V617F
BCR-ABL1
PML-RARA
FLT3 & NPM1
CLL sequencing for somatic hypermutation
CYTOGENETICS
Break Apart Rearrangement Probes
ALK (2p23)
AML1 (21q22)
BCL2 (18q21)
BCL3 (19q13)
BCL6 (3q27)
BCL10 (1p22)
CBFB (16q22)
CCND1 (11q13)
ETV6 (TEL) (12p13)
EVI1 (MECOM) (3q26.2)
EWSR1 (22q11.2)
FGFR1 (8p12)
IGH (14q32)
IGK (2p11)
IGL (22q11)
MALT1 (18q21)
MLL (11q23)
MYC (8q24)
MYCN (2P23-24) (for amp)
PAX5 (9p13)
PDGFRB (5q33)
RARA (17q21)
TCRB (7q34)
TCRG (7p14)
TCRAD (14q11)
TCR3 (19p13)
TCL1(14q32.1)
Order Blanks - See Page One
Other
Translocation Probes
ASS deletion (9q34)
ATM deletion (11q22.3)
CEP X/Y
D7S486/CEP7 -7/7q31 I (7q)
(D7S522/CEP7) - 7/7q31
Deletion 13q (13q14) D135319
Deletion 20q (20q12) D205108
EGR1 -5/5q-
RUNX1T1/RUNX1 (ETO/AML1) t(8;21) AML
FIP1L1-CHIC2-PDGFRA(4q12) (CHIC2 deletion)
BIRC3-MALT1 (API2-MALT1) t(11;18)
CDKN2A (p16) (9p21 deletion)
TP53 deletion (17p13.1)
Trisomy 5, 9, 15
Trisomy 8 D8Z2
Trisomy 12 D1273
BCR-ABL t(9;22) CML/ALL/AML
IGH - CCND1 (T11:14)
IGH-BCL2 t(14;18)
CBFB-MYH1 (16p13/16q22) t(16;16). inv(16)
IGH-FGFR3 t(4;14)
IGH-MAF t(14;16)
IGH MALT1 t(14;18)
IGH-MYC t(8;14)
PML-RARA t(15;17)
TEL-AML1 (ETV6/RUNX1) t(12;21)
Panels
B-Cell Lymphoma - BCL6 (3q27) / MYC (8q24) / IGH (14q32.3) / BCL2 (18q21)
CLL - MYB (6q23) / ATM (11q22.3) / trisomy 12 / D13S319 (13q14.3) / IGH (14q32.3) / p53 (17p13.1)
Multiple Myeloma MM - D13S319 (13q14.3) / ATM (11q22.3) / p53 (17p13.1) / IGH (14q32.3) / CCND1 (11q13)
Childrens' ALL - CEP4/CEP10/CEP17 (trisomies 4, 10, 17) / BCR/ABL [t(9;22)] / MLL (11q23) / TEL-AML1 (ETV6/RUNX1) t((12;21)
Childrens' AML - EGR1 (5q31) / monosomy 7 / ETO-AML1 (RUNX1T1/RUNX1) [t(8;21)] / MLL (11q23) / CBFB [inv(16)]
MDS/AML - EGR1 (5q31) / D7S486 (7q31)-CEP7 / trisomy 8 / D2OS108 (20q12)
AML Panel - EGR1 (5q31) / D7Z1 - D7S486 / RUNX1T1-RUNX1[t(8;21)] / CBFB [inv(16) or t(16;16)] / MLL [t(11;var)]
[as needed (i.e. if not seen by classical analysis)]
MPD panel - BCR-ABL1 / CEP8 / CEP9 / D2OS108 (20q12)
Myeloid/lymphoid neoplasm with eosinophilia - FIP1L1-CHIC2-PDGFRA (4q12), PDGFRB (5q33), FGFR1 (8p13)
Additional FISH Probes Request (please list) Requested Ordered Blanks Sent
Comments
Filing of Slides
Location of Lymph Node slides
Before 1992 (LN were part of Surgical Pathology Section) - Iron Mountain
SEPT 1992 to PHS13-31654
PHS13-31654 - present
- Iron Mountain
-G325.1 Bone marrow
Reading room PUH
Starting April, 2009 - LN surgical pathology requisitions are stored in the CLB, in room 9032,
near the grossing station.
Lymph Node Rotation Checklist
including fellows.
 Orientation with (Fellowship Director) or designate.
 Orientation with Dr. Gibson (Resident Director) or designate.
 Done prior rotation
 New rotation
 Orientation by experienced trainee.
 Orientation by Lymph Node Assistant or designate.
 Competent and comfortable with gross processing and triaging of fresh lymph nodes and
spleens and other specimens with possible hematopoietic/lymphoid disorders.
 Competent and comfortable to construct, dictate and proof full reports and to order stains using
CoPath.
 Knows normal architecture and immunoarchitecture of lymph node, spleen and Peyer’s Patch.
 Knows reactivity of all antibodies used in flow cytometry panel to assess hematopoietic/lymphoid
disorders in lymph node, spleen and all other extranodal sites (panels in resident/fellow
handbook).
 Confidently can interpret flow cytometry data including histograms.
 Knows role of cytogenetic and molecular diagnostic studies in evaluating
hematopoietic/lymphoid disorder in lymph node, spleen and other extranodal sites.
Learned diagnostic criteria using multiparameter approach and clinical implications for
each of the following in lymph nodes and extranodal sites (residents to
accomplish at least lower case items in bold, fellows to accomplish all over one
year):
Diagnosis / Finding
Observed
Actual
Case
Observed
Teaching
File Case
Read
about
NON-NEOPLASTIC DISORDERS (NODAL)
Viral-associated adenitis (infectious mononucleosis,
postvaccinal, herpes zoster, cytomegalovirus,
measles, HIV)



Syphilis



Toxoplasmosis



Diagnosis / Finding
Observed
Actual
Case
Observed
Teaching
File Case
Read
about
Cat-scratch disease



Granulomatous processes



Whipple’s disease



Bacillary angiomatosis



Autoimmune disorders (Rheumatoid arthritis,
Sjögren’s syndrome, Adults Still’s disease, systemic
lupus erythematosus)






Angiofollicular hyperplasia/Castleman’s Disease



Inflammatory pseudotumor



Dermatopathic lymphadenopathy



Sinus histiocytosis with massive adenopathy
(Rosai-Dorfman)



Histiocytic Necrotizing Lymphadenitis



Kimura’s disease/angiolymphoid hyperplasia with
eosinophilia



Drug reactions (Dilantin, Tegretol)



Hemophagocytic syndrome



Immunodeficiency states (including ALPS, other)



B lymphoblastic leukaemia/lymphoma



T lymphoblastic leukaemia/lymphoma



Chronic lymphocytic leukaemia/small
lymphocytic lymphoma












Sarcoidosis
MALIGNANT LYMPHOMAS
Extranodal marginal zone lymphoma of mucosaassociated lymphoid tissue (MALT lymphoma)
Nodal marginal zone lymphoma
Diagnosis / Finding
Observed
Actual
Case
Observed
Teaching
File Case
Read
about
Follicular lymphoma



Primary cutaneous follicle centre lymphoma






Diffuse large B-cell lymphoma (DLBCL), NOS



T-cell/histiocyte rich large B-cell lymphoma



Primary DLBCL of the CNS



Primary cutaneous DLBCL, leg type



EBV positive DLBCL of the elderly



DLBCL associated with chronic inflammation



Lymphomatoid granulomatosis



Primary mediastinal (thymic) large B-cell
lymphoma






ALK positive DLBCL



Plasmablastic lymphoma



Large B-cell lymphoma arising in associated
multicentric Castleman disease



Primary effusion lymphoma



Burkitt lymphoma



High grade B-Cell lymphoma, MYC and BCL2
and/or BCL6 rearrangements
(High grade B-cell lymphoma, NOS)



B-cell lymphoma, unclassifiable, with features
intermediate between diffuse large B-cell lymphoma
and classical Hodgkin lymphoma



Adult T-cell leukaemia/lymphoma



Extranodal NK/T cell lymphoma, nasal type



Enteropathy-associated T-cell lymphoma



Diagnosis / Finding
Observed
Actual
Case

Observed
Teaching
File Case

Read
about













Lymphomatoid papulosis



Primary cutaneous anaplastic large lymphoma



Primary cutaneous gamma-delta T-cell lymphoma



Primary cutaneous CD8 positive aggressive
epidermotropic
Primary cutaneous CD4 positive small/medium T-cell
lymphoma






Peripheral T-cell lymphoma, NOS






Anaplastic large cell lymphoma, ALK positive



Anaplastic large cell lymphoma, ALK negative



Nodular lymphocyte predominant Hodgkin
lymphoma









Plasmacytic hyperplasia



Infectious-mononucleosis-like PTLD






Monomorphic PTLD, B-cell types, T-cell types



Hodgkin lymphoma type PTLD



Subcutaneous panniculitis-like T-cell lymphoma
Mycosis fungoides
Sézary syndrome
Primary cutaneous CD30 positive T-cell
lymphoproliferative disorders
POST-TRANSPLANT LYMPHOPROLIFERATIVE
DISORDER
Early lesions
Polymorphic PTLD
HISTIOCYTIC AND DENDRITIC CELL
NEOPLASMS
Diagnosis / Finding
Histiocytic sarcoma
Observed
Actual
Case

Observed
Teaching
File Case

Read
about







Follicular dendritic cell sarcoma



OTHER NEOPLASMS
Mastocytosis



Myeloid sarcoma



Blastic Plasmacytoid dendritic cell tumor



Metastatic tumors



Langerhans cell histiocytosis/sarcoma
Interdigitating dendritic cell sarcoma
Learned diagnostic criteria for the following in the SPLEEN (residents to accomplish at least
items in lower case bold, fellows to accomplish all over one year):
Diagnosis / Finding
Observed
Actual
Case
Observed
Teaching
File Case
Read
about















Hereditary spherocytosis



Acquired immune deficiency syndrome



Bacterial infections including bacillary angiomatosis



Viral infections including infectious
mononucleosis



Castleman disease



Fibrocongestive splenomegaly



Histiocytic proliferations



BENIGN
Localized lymphoid hyperplasia
Changes in benign systemic and infectious disorders
Rheumatoid arthritis (Felty’s syndrome)
Autoimmune thrombocytopenic purpura
Thrombotic thrombocytopenic purpura















Chronic lymphocytic leukemia / Small lymphocytic
lymphoma
























Other non-Hodgkin’s lymphomas



Prolymphocytic leukemia



Large granular lymphocytic leukemia



Chronic myeloid leukemia



Chronic myeloproliferative neoplasm



Hairy cell leukemia



Acute leukemias















Lipid histiocytes
Ceroid histiocytosis
Gaucher’s disease
Hemophagocytic syndrome
SPLENIC EXPRESSION OF THE FOLLOWING
LYMPHOMAS
Splenic and other marginal zone B-cell
lymphomas
Splenic lymphoma/leukaemia, unclassifiable
Follicular lymphoma
Diffuse large B-cell lymphoma
CHANGES IN LEUKEMIAS AND
MYELOPROLIFERATIVE DISORDERS
Systemic mastocytosis
NONHEMATOPOIETIC LESIONS
Developmental cysts
Developmental hamartomas
Vascular neoplasms
Hemangiomas









Nonvascular sarcomas



Metastases



Inflammatory pseudotumor



Lymphangiomas
Littoral-cell angiomas
Angiosarcomas
PRESENTED THE FOLLOWING “LYMPH NODE” CASES (Submit Presentation in Portfolio).
PHS NUMBER
DIAGNOSIS
UTILIZED THE FOLLOWING LYMPH NODE RESOURCES

Lymph node chapter in Sternberg.

Swerdlow, S.H., Campo, E., Harris, N.L., Jaffe, E., Pileri, S.A., Stein, H., Thiele, J., Vardiman, J.
(Eds.): WHO Classification of Tumours Pathology of Haematopoietic and Lymphoid Tumours,
IARC, Lyon, 2008. [Highly recommended]

Checkpath (images, histories and explanations of faculty CME program for Hematopathology)
(PUH G315 and in Dr. Swerdlow’s coordinator’s office).

Teaching/conference sets of glass slides of marrows, lymph nodes, etc. (Dr. Swerdlow’s office).

Jaffe, E.S., Harris, N.L., H. Vardiman, J.W., Campo, E., Arber, Daniel A., Hematopathology,
2011 (G323)

O’Malley D.P., George, T.I., Orazi A., Benign and Reactive Conditions of Lymph Node and
Spleen, 2009.
NOTE: Reading is an important component of this rotation. It is recognized that not all of the above
resources can be used nor can most be read in entirety. Use of electronic and other resources to find
and read up-to-date journal articles is also critical.
I have completed the Lymph Node Checklist
Name __________________________________________ (printed)
__________________________________________ (signature)
Date
__________________________________________
Protocol for the Examination of Specimens From Patients With
Non-Hodgkin Lymphoma/Lymphoid Neoplasms
Protocol applies to non-Hodgkin lymphoma/lymphoid neoplasms involving any site
except the ocular adnexa, bone marrow, mycosis fungoides, and Sezary syndrome.
Protocol web posting date: October 2013
Procedures
• Biopsy
• Resection of Lymph Node(s) or Other Organ(s)
Authors
Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California
Daniel A. Arber, MD
Department of Pathology, Stanford University School of Medicine, Stanford, California
Department of Pathology and Laboratory Medicine, Emory University Hospital, Atlanta, Georgia
Department of Pathology, Yellowstone Pathology Institute Inc, Billings, Montana
Department of Pathology, The Methodist Hospital, Houston, Texas
Department of Pathology and Laboratory Medicine, Physicians Laboratory Ltd, Sioux Falls, South Dakota
Department of Anatomical Pathology, Flinders Medical Centre, Bedford Park, South Australia
Department of Pathology, University of New Mexico, Albuquerque, New Mexico
Department of Clinical Pathology, Cleveland Clinic Foundation, Cleveland, Ohio
Elaine S. Jaffe, MD
Hematopathology Section, Laboratory of Pathology, National Cancer Institute, Bethesda, Maryland
Joseph Khoury, MD, FCAP
Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
Department of Pathology and Laboratory Medicine, Presbyterian Pathology Group, Charlotte, North
Carolina
Department of Hematopathology, MD Anderson Cancer Center, Houston, Texas
Department of Pathology, Hematopathology, University of Utah Health Sciences Center, Salt Lake City,
Utah
* Denotes the primary and senior author. All other contributing authors are listed alphabetically.
Surgical Pathology Cancer Case Summary
NON-HODGKIN LYMPHOMA/LYMPHOID NEOPLASMS: Biopsy, Resection
Select a single response unless otherwise indicated.
Specimen (select all that apply) (note A)
Lymph node(s)
Other (specify):
Not specified
Procedure
Biopsy
Resection
Other (specify):
Not specified
Tumor Site (select all that apply) (note B)
Lymph node(s), site not specified
Lymph node(s)
Specify site(s):
Other tissue(s) or organ(s):
Not specified
Histologic Type (note C)
Histologic type cannot be assessed
B lymphoblastic leukemia/lymphoma,
B lymphoblastic leukemia/lymphoma
leukemia/lymphoma [ALL])
not otherwise specified (NOS)#
with t(9;22)(q34;q11.2); BCR-ABL1
with t(v;11q23); MLL rearranged
with t(12;21)(p13;q22); TEL-AML1 (ETV6-RUNX1)
with hyperdiploidy
with hypodiploidy (hypodiploid acute lymphoblastic
with t(5;14)(q31;q32); IL3-IGH
with t(1;19)(q23;p13.3); E2A-PBX1 (TCF3-PBX1)
T lymphoblastic leukemia/lymphoma
B-cell lymphoma, subtype cannot be determined (Note: not a category within the WHO
classification)
Chronic lymphocytic leukemia/small lymphocytic lymphoma
Splenic B-cell marginal zone lymphoma
Hairy cell leukemia
Splenic B-cell lymphoma/leukemia, unclassifiable
Splenic diffuse red pulp small B-cell lymphoma
Hairy cell leukemia-variant
Gamma heavy chain disease
Mu heavy chain disease
Alpha heavy chain disease
Plasma cell myeloma
Solitary plasmacytoma of bone
Extraosseous plasmacytoma
Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma)
Pediatric nodal marginal zone lymphoma
Follicular lymphoma
Pediatric follicular lymphoma
Primary intestinal follicular lymphoma
Primary cutaneous follicle center lymphoma
T cell/histiocyte-rich large B-cell lymphoma
Primary DLBCL of the central nervous system (CNS)
Primary cutaneous DLBCL, leg type
Epstein-Barr virus (EBV)-positive DLBCL of the elderly
Primary mediastinal (thymic) large B-cell lymphoma
Anaplastic lymphoma kinase (ALK)-positive large B-cell lymphoma
Large B-cell lymphoma arising in HHV8-associated multicentric Castleman disease
Burkitt lymphoma
B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma
and Burkitt lymphoma
B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma
Other (specify):
Mature T- and NK-Cell Neoplasms
T-cell lymphoma, subtype cannot be determined (Note: not a category within the WHO
classification)
T-cell large granular lymphocytic leukemia
Chronic lymphoproliferative disorder of NK cells
Systemic EBV-positive T-cell lymphoproliferative disease of childhood
Hydroa vacciniforme-like lymphoma
Extranodal NK/T-cell lymphoma, nasal type
Primary cutaneous anaplastic large cell lymphoma
Primary cutaneous CD8-positive aggressive epidermotropic cytotoxic T-cell lymphoma
Primary cutaneous CD4-positive small/medium T-cell lymphoma
Anaplastic large cell lymphoma, ALK-positive
Anaplastic large cell lymphoma, ALK-negative
Other (specify):
Histiocytic sarcoma
Langerhans cell sarcoma
Fibroblastic reticular cell tumor
Indeterminate dendritic cell tumor
Disseminated juvenile xanthogranuloma
Posttransplant Lymphoproliferative Disorders (PTLD)##
Early lesions:
Infectious mononucleosis-like PTLD
Polymorphic PTLD
Monomorphic PTLD (B- and T/NK-cell types)
Specify subtype:
Classical Hodgkin lymphoma type PTLD###
Note: Italicized histologic types denote provisional entities in the 2008 WHO classification.
An initial diagnosis of “B lymphoblastic leukemia/lymphoma, NOS” may need to be given before the cytogenetic
results are available.
#
##
These disorders are listed for completeness, but not all of them represent frank lymphomas.
Classical Hodgkin lymphoma type PTLD can be reported using either this protocol or the separate College of
American Pathologists protocol for Hodgkin lymphoma.1
###
+ Pathologic Extent of Tumor (select all that apply) (note D)
+
Bone marrow involvement
+
Other site involvement
+ Specify site(s):
+ Additional Pathologic Findings
+ Specify:
Immunophenotyping (flow cytometry and/or immunohistochemistry) (note E)
Performed, see separate report:
Performed
Specify method(s) and results:
Not performed
+ Cytogenetic Studies (note E)
+
+
Performed
+ Specify method(s) and results:
+
Not performed
+ Molecular Genetic Studies (note E)
+
+
Performed
+ Specify method(s) and results:
+
Not performed
+ Clinical Prognostic Factors and Indices (select all that apply) (note F)
+
International Prognostic Index (IPI) (specify):
+
Follicular Lymphoma International Prognostic Index (FLIPI) (specify):
+
B symptoms present
+
Other (specify):
+ Comment(s)
+ Data elements preceded by this symbol are not required. However, these elements may be clinically important but are not yet
validated or regularly used in patient management.
Explanatory Notes
A. Specimen
Any number of specimen types may be submitted in the evaluation of lymphoid neoplasms. Lymph
nodes, skin, gastrointestinal (GI) tract, bone marrow, spleen, thymus, and tonsils are among the most
common. Specimens submitted with a suspected diagnosis of lymphoma require special handling in
order to optimize the histologic diagnosis and to prepare the tissue for molecular and other ancillary
special studies.2,3 The guidelines detailed below are suggested for specimen handling in cases of
suspected lymphoma.
• Tissue should be received fresh. Unsectioned lymph nodes should not be immersed in fixative, and
care should be taken to make thin slices of the node to ensure optimal penetration of fixative.
• The fresh specimen size, color, and consistency should be recorded, as should the presence or
absence of any visible nodularity, hemorrhage, or necrosis after serial sectioning at 2-mm intervals
perpendicular to the long axis of the lymph node.
• Touch imprints may be made from the freshly cut surface, and the imprints fixed in alcohol or air
dried.
• For cytogenetic studies or culture of microorganisms: submit a fresh portion of the node (or other
specimen type) sterilely in appropriate medium.
• For immunophenotyping by flow cytometry: submit a fresh portion of the specimen in appropriate
transport medium such as RPMI.
• Fixation (record fixative[s] used for individual slices of the specimen):
o Estimated time from excision to fixation should be noted, if possible, as this may impact
preservation or recovery of certain analytes such as RNA and phosphoproteins in fixed tissues.
o Zinc formalin or B5 produces superior cytologic detail but is not suitable for DNA extraction and
may impair some immunostains (eg, CD30). B5 also has the additional limitation of requiring
proper hazardous-materials disposal.
o Formalin fixation is preferable when the tissue sample is limited, as it is most suitable for many
ancillary tests such as molecular/genetic studies, in-situ hybridization, and immunophenotyping.
o Over-fixation (ie, more than 24 hours in formalin, more than 4 hours in zinc formalin or B5) should
be avoided for optimal immunophenotypic reactivity.
• Snap-frozen tissue is optimal for DNA and RNA extraction.
o Place in aluminum foil or cover in OCT.
o Immerse in dry ice/isopentane slush or liquid nitrogen.
o Store at -80°C until needed.
B. Tumor Site
The anatomic sites that constitute the major structures of the lymphatic system include groups and
chains of lymph nodes, the spleen, the thymus, Waldeyer’s ring (a circular band of lymphoid tissue that
surrounds the oropharynx, consisting of the palatine, lingual, and pharyngeal tonsils), the vermiform
appendix, and the Peyer’s patches of the ileum.2,3 Minor sites of lymphoid tissue include the bone
marrow, mediastinum, liver, skin, lung, pleura, and gonads. Involvement of extranodal sites is more
common in non-Hodgkin lymphomas (NHL) than in Hodgkin lymphoma. In addition, some NHL, such as
mycosis fungoides and extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue
(MALT), occur predominantly or entirely in extranodal sites.
C. Histologic Type
This protocol recommends assigning histologic type based on the World Health Organization (WHO)
classification of lymphoid neoplasms.4 It was originally published in 2001 and recently was revised and
updated in 2008.5 This classification encompasses both nodal and extranodal lymphomas and provides
distinction of individual lymphoid neoplasms based upon morphologic, immunophenotypic,
cytogenetic, and clinical features. While histologic examination typically is the gold standard, the
majority of the lymphoid neoplasms will require the utilization of 1 or more other ancillary techniques,
such as immunophenotyping, molecular studies, and/or cytogenetics, to arrive at the correct
diagnosis.4-10 If the specimen is inadequate or suboptimal for a definitive diagnosis and subtyping, this
information should also be relayed to the clinician with an explanation of what makes the specimen
inadequate or suboptimal.
D. Pathologic Extent of Tumor (Stage)
In general, the TNM classification has not been used for staging of lymphomas because the site of origin
of the tumor is often unclear and there is no way to differentiate among T, N, and M. Thus, a special
staging system (Ann Arbor system) is used for both Hodgkin lymphoma and NHL.11,12 It was originally
published over 30 years ago for staging Hodgkin lymphoma. The Ann Arbor classification for
lymphomas has been applied to NHL by the American Joint Committee on Cancer (AJCC)13 and the
14
International Union Against Cancer (UICC) except for mycosis fungoides and Sezary syndrome.
For multiple myeloma, the Durie-Salmon staging system is recommended by the AJCC.13-15 The
international staging system for multiple myeloma is useful for determining survival.13 The Ann Arbor
classification and Durie-Salmon staging systems are shown below. It should also be realized that the St.
Jude staging system is commonly used for pediatric patients.16
Historically, pathologic staging depended on the biopsy of multiple lymph nodes on both sides of the
diaphragm, splenectomy, wedge liver biopsy, and bone marrow biopsy to assess distribution of disease.
Currently, staging of NHL is more commonly clinical than pathologic. Clinical staging generally involves
a combination of clinical, radiologic, and surgical data. Physical examination, laboratory tests (eg,
complete blood examination and blood chemistry studies including lactate dehydrogenase [LDH] and
liver function tests), imaging studies (eg, computed tomography scans, magnetic resonance imaging
studies, and positron emission tomography), biopsy (to determine diagnosis, histologic type, and extent
of disease), and bone marrow examination are often required. In patients at high risk for occult CNS
involvement, cerebrospinal fluid cytology should be performed.
17-20
There is almost universal agreement that the stage of the NHL is prognostically significant.
Correct
diagnosis and staging are the key factors in National Comprehensive Cancer Network treatment
21
schema that most clinicians utilize.
AJCC/UICC Staging for Non-Hodgkin Lymphomas
Stage I
Involvement of a single lymph node region (I), or localized involvement of a single
extralymphatic organ or site in the absence of any lymph node involvement (IE)#, ##
Stage II
Involvement of 2 or more lymph node regions on the same side of the diaphragm (II), or
localized involvement of a single extralymphatic organ or site in association with regional
lymph node involvement with or without involvement of other lymph node regions on
the same side of the diaphragm (IIE) ##,###
Stage III
Involvement of lymph node regions on both sides of the diaphragm (III), which also may
be accompanied by extralymphatic extension in association with adjacent lymph node
involvement (IIIE) or by involvement of the spleen (IIIS) or both (IIIE+S) ##,###,^
Stage IV
Diffuse or disseminated involvement of 1 or more extralymphatic organs, with or without
associated lymph node involvement; or isolated extralymphatic organ involvement in
the absence of adjacent regional lymph node involvement, but in conjunction with
disease in distant site(s). Stage IV includes any involvement of the liver, bone marrow, or
nodular involvement of the lung(s) or cerebral spinal fluid. ##,###,^
#
Multifocal involvement of a single extralymphatic organ is classified as stage IE and not stage IV.
##
For all stages, tumor bulk greater than 10 to 15 cm is an unfavorable prognostic factor.
The number of lymph node regions involved may be indicated by a subscript: eg, II3. For stages II to
IV, involvement of more than 2 sites is an unfavorable prognostic factor.
###
^
For stages III to IV, a large mediastinal mass is an unfavorable prognostic factor.
Note: Direct spread of a lymphoma into adjacent tissues or organs does not influence classification of
stage.
AJCC/UICC Staging for Plasma Cell Myeloma
Stage I
Hemoglobin greater than 10.0 g/dL
Serum calcium 12 mg/dL or less
Normal bone x-rays or a solitary bone lesion
IgG less than 5 g/dL
IgA less than 3 g/dL
Urine M-protein less than 4 g/24 hours
Stage III
One or more of the following are included:
Hemoglobin less than 8.5 g/dL
Serum calcium greater than 12 mg/dL
Advanced lytic bone lesions
IgG greater than 7 g/dL
IgA greater than 5 g/dL
Urine M-protein greater than 12 g/24 hours
Stage II
Disease fitting neither stage I nor stage III
Note: Patients are further classified as (A) serum creatinine less than 2.0 mg/dL or (B) serum creatinine
2.0 mg/dL or greater. The median survival for stage IA disease is about 5 years, and that for stage IIIB
disease is 15 months.13,14
E. Immunophenotyping and Molecular Genetic Studies
Immunophenotyping can be performed by flow cytometry8 or immunohistochemistry. Each has its
advantages and disadvantages. Flow cytometry is rapid (hours), quantitative, and allows multiple
antigens to be evaluated on the same cell simultaneously. Antigen positivity, however, cannot be
correlated with architecture or cytologic features. Immunohistochemistry requires hours/days to
perform, quantitation is subjective, but importantly it allows correlation of antigen expression with
architecture and cytology. Not all antibodies are available for immunohistochemistry, particularly in
fixed tissues, but one of its advantages is that it can be performed on archival tissue. Both techniques
can provide diagnostic as well as clinically relevant information (eg, identification of therapeutic targets
such as CD20). Molecular studies now play an increasingly important role in the diagnosis of
hematopoietic neoplasms. They aid not only in helping establish clonality but also in determining
lineage, establishing the diagnosis of specific disease entities, and monitoring minimal residual
10,22-24
disease.
Immunophenotypes and Genetics
The following is to be used as a guideline for the more common immunophenotyping and cytogenetic
findings for each entity.3,4,8,22-27 It is however, not entirely comprehensive and individual cases may vary
somewhat in their immunophenotypic and cytogenetic profile.
B Lymphoblastic Leukemia/Lymphoma, NOS: sIG-, cytoplasmic µ chain (30%), CD19+, CD20-/+, CD22+,
PAX5+, CD79a+, TdT+, HLA-DR+, CD10+/-, CD34+/-, CD13-/+, CD33-/+, IGH gene rearrangement +/-, IGL
gene rearrangement -/+, TCR gene rearrangement -/+, variable cytogenetic abnormalities
B Lymphoblastic Leukemia/Lymphoma With t(9;22)(q34;q11.2); BCR-ABL1: sIG-, cytoplasmic µ chain
(30%), CD19+, CD20-/+, CD22+, PAX5+, CD79a+, TdT+, HLA-DR+, CD10+/-, CD34+/-, CD13-/+, CD33-/+,
IGH gene rearrangement +/-, IGL gene rearrangement -/+, TCR gene rearrangement -/+,
t(9;22)(q34;q11.2), may have either p190 kd or p210 kd BCR-ABL1 fusion protein.
B Lymphoblastic Leukemia/Lymphoma With t(v;11q23); MLL Rearranged: sIG-, cytoplasmic µ chain
(30%), CD19+, CD20-/+, CD22+, PAX5+, CD79a+, TdT+, HLA-DR+, CD10-, CD34+/-, CD13-/+, CD33-/+,
CD15 +/-, IGH gene rearrangement +/-, IGL gene rearrangement -/+, TCR gene rearrangement -/+,
t(v;11q23)
B Lymphoblastic Leukemia/Lymphoma With t(12;21)(p13;q22); TEL-AML1 (ETV6-RUNX1): sIG-, cytoplasmic
µ chain (30%), CD19+, CD20-, CD22+, PAX5+, CD79a+, TdT+, HLA-DR+, CD10+, CD34+/-, CD13+/-, CD33/+, CD15 +/-, IGH gene rearrangement +/-, IGL gene rearrangement -/+, TCR gene rearrangement -/+,
t(12;21)(p13;q22)
B Lymphoblastic Leukemia/Lymphoma With Hyperdiploidy: sIG-, cytoplasmic µ chain (30%), CD19+,
CD20-/+, CD22+, PAX5+, CD79a+, TdT+, HLA-DR+, CD10+/-, CD34+/-, CD13-/+, CD33-/+, IGH gene
rearrangement +/-, IGL gene rearrangement -/+, TCR gene rearrangement -/+, hyperdiploid (>50
chromosomes, often with extra copies of chromosomes 21, X, 4 and 14) without structural abnormalities
B Lymphoblastic Leukemia/Lymphoma With Hypodiploidy: sIG-, cytoplasmic µ chain (30%), CD19+,
CD20-/+, CD22+, PAX5+, CD79a+, TdT+, HLA-DR+, CD10+/-, CD34+/-, CD13-/+, CD33-/+, IGH gene
rearrangement +/-, IGL gene rearrangement -/+, TCR gene rearrangement -/+, hypodiploid with 45
chromosomes to near haploid
B Lymphoblastic Leukemia/Lymphoma With t(5;14)(q31;q32); IL3-IGH: sIG-, cytoplasmic µ chain (30%),
CD19+, CD20-, CD22+, PAX5+, CD79a+, TdT+, HLA-DR+, CD10+, CD34+/-, CD13+/-, CD33-/+, CD15 +/-,
IGH gene rearrangement +/-, IGL gene rearrangement -/+, TCR gene rearrangement -/+,
t(5:14)(q31;q32)
B Lymphoblastic Leukemia/Lymphoma With t(1;19)(q23;p13.3); E2A-PBX1 (TCF3-PBX1): sIG-, cytoplasmic
µ chain (30%), CD19+, CD20-, CD22+, PAX5+, CD79a+, TdT+, HLA-DR+, CD10+, CD34+/-, CD13+/-, CD33/+, CD15 +/-, IGH gene rearrangement +/-, IGL gene rearrangement -/+, TCR gene rearrangement -/+,
t(1;19)(q23;p13.3)
T Lymphoblastic Leukemia/Lymphoma: TdT+, CD7+, CD3+/- (usually surface CD3-), variable expression
of other PanT antigens, CD1a+/-, often CD4 and CD8 double positive or double negative, IG-, PanB-;
variable TCR gene rearrangements; IGH gene rearrangement -/+, chromosomal abnormalities are
common and often involve 14q11-14, 7q35, or 7p14-15
Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma: Faint sIGM+, sIGD+/-,
cIG-/+, panB+ (CD19+, CD20+), CD5+, CD10-, CD23+, CD43+, CD11c-/+; IGH and IGL gene
rearrangements; trisomy 12; del 13q, del(17p), or del(11q) can be seen
B-Cell Prolymphocytic Leukemia: sIgM, sIgD+/-, pan B+ (CD19, CD20, CD22, CD79a, CD79b and FMC-7),
CD5 -/+, CD23-/+, del(17p), t(11;14)(q13;q32), breakpoints involving 13q14
Splenic B-Cell Marginal Zone Lymphoma: sIGM+, sIGD+/-, CD20+, CD79a+, CD5-, CD10-, CD23-, CD43-,
nuclear cyclin D1-, CD103-, allelic loss at 7q31-32 (40%)
Hairy Cell Leukemia: sIG+ (IGM, IGD, IGG, or IGA), PanB+, CD79a+, CD79b-, DBA.44+, CD123+, CD5-,
CD10-, CD23-, CD11c+, CD25+, FMC7+, CD103+ (mucosal lymphocyte antigen as detected by B-ly7),
tartrate resistant acid phosphatase (TRAP)+; IGH and IGL gene rearrangements, no specific cytogenetic
findings
Splenic Diffuse Red Pulp Small B-Cell Lymphoma: sIGG+, sIGD-/+, sIGM+/-, CD20+, DBA.44+, CD5-,
CD103-/+, CD123-, CD25-, CD11c-/+, CD10-, CD23-, t(9;14)(p13;q32) occasionally seen, rarely
abnormalities in TP53 or del 7q
Hairy Cell Leukemia-Variant: sIGG+, PanB+, DBA.44+, CD11c+, CD103+, FMC7+, CD25-, CD123-, Annexin
A1-, TRAP-IHC-, no specific cytogenetic findings
Lymphoplasmacytic Lymphoma: sIGM+, sIGD-/+, cIG+, PanB+, CD19+, CD20+, CD138+ (in plasma
cells), CD79a+, CD5-, CD10-, CD43+/-, CD25-/+; IGH and IGL gene rearrangements, no specific
cytogenetic findings
Alpha Heavy Chain Disease (Immunoproliferative Small Intestinal Disease): cytoplasmic alpha heavy
chain+, CD20+ (lymphocytes), CD138+ (plasma cells), light chainGamma Heavy Chain Disease: IgG heavy chain+, CD79a+, CD20+ (on lymphocytes), CD138+ (in
plasma cells), CD5-, CD10-, light chain-, abnormal karyotype in 50% without recurring abnormalities
Mu Heavy Chain Disease: monoclonal cytoplasmic mu heavy chain+, B-cell antigen+, CD5-, CD10-,
surface light chainPlasma Cell Myeloma: cIG+ (IGG, IGA, rare IGD, IGM, or IGE or light chain only), PanB-(CD19-, CD20-,
CD22-), CD79a+/-, CD45-/+, HLA-DR-/+, CD38+, CD56+/-, CD138+, EMA-/+, CD43+/-, cyclin D1+; IGH
and IGL gene rearrangements; numerical and structural chromosomal abnormalities are common,
including trisomies (often involving odd numbered chromosomes), deletions (most commonly involving
13q14), and translocations (often involving 14q32)
Solitary Plasmacytoma of Bone: cIG+ (IGG, IGA, rare IGD, IGM, or IGE or light chain only), PanB-(CD19-,
CD20-, CD22-), CD79a+/-, CD45-/+, HLA-DR-/+, CD38+, CD56+/-, CD138+, EMA-/+, CD43+/-, cyclin D1+;
IGH and IGL gene rearrangements; deletions, most commonly 13q, and occasional translocations, in
particular t(11;14)(q13;q32)
Extraosseous Plasmacytoma: cIG+ (IGG, IGA, rare IGD, IGM, or IGE or light chain only), PanB-(CD19-,
CD20-, CD22-), CD79a+/-, CD45-/+, HLA-DR-/+, CD38+, CD56+/-, CD138+, EMA-/+, CD43+/-, cyclin D1+;
IGH and IGL gene rearrangements; deletions, most commonly 13q, and occasional translocations, in
particular t(11;14)(q13;q32)
Extranodal Marginal Zone Lymphoma of Mucosa-Associated Lymphoid Tissue
(MALT Lymphoma): sIG+ (IGM or IGA or IGG), sIGD-, cIG-/+, PanB+, CD5-, CD10-, CD23-, CD43-/+; IGH
and IGL gene rearrangements, BCL1 and BCL2 germline, trisomy 3 or t(11;18)(q21;q21) may be seen
Nodal Marginal Zone Lymphoma: sIGM+, sIGD-, cIG-/+, PanB+, CD5-, CD10-, CD23-, CD43-/+; IGH and
IGL gene rearrangements, BCL1 and BCL2 germline
Follicular Lymphoma: sIG+ (usually IGM +/- IGD, IGG, IGA), PanB+, CD10+/-, CD5-/+, CD23-/+, CD43-,
CD11c-, CD25-; overexpression of BCL2+ (useful to distinguish from reactive follicles), BCL6+; IGH and IGL
gene rearrangements, t(14;18)(q32;q21) with rearranged BCL2 gene (70-95% in adults)
Pediatric Follicular Lymphoma: sIG+ (usually IGM +/- IGD, IGG, IGA), PanB+, CD10+/-, CD5-, CD23-/+,
CD43-, CD11c-, CD25-; overexpression of BCL2-, BCL6+, t(14;18) with rearranged BCL2 gene Primary Cutaneous Follicle Center Lymphoma: CD20+, CD79a+, CD10+/-, BCL2-/+, BCL6+, CD5-, CD43-,
BCL2 gene rearrangement-/+
Mantle Cell Lymphoma: sIGM+, sIGD+, lambda>kappa, PanB+, CD5+, CD10-/+, CD23-, CD43+, CD11c-,
CD25-, cyclin D1+; IGH and IGL gene rearrangements, t(11;14)(q13;q32); BCL1 gene rearrangements
(CCND1/cyclinD1) common
Diffuse Large B-Cell Lymphoma (DLBCL), NOS: PanB+, surface or cytoplasmic IGM>IGG>IGA, CD45+/-,
CD5-/+, CD10+/-, BCL6 +/-, 3q27 region abnormalities involving BCL6 seen in 30% of cases, t(14;18)
involving BCL2 seen in 20-30% of cases, MYC rearrangement seen in 10% of cases
T Cell/Histiocytic-Rich Large B-Cell Lymphoma: PanB+, BCL6+, BCL2-/+, EMA -/+, background comprised
of CD3 and CD5 positive T-cells and CD68+ histiocytes
Primary DLBCL of the CNS: CD20+, CD22, CD79a, CD10-/+, BCL6+/-, IRF4/MUM1+/-, BCL2+/-, BCL6
translocations+/-, del 6q and gains of 12q, 22q, and 18q21 common
Primary Cutaneous DLBCL, Leg Type: sIG+, CD20+, CD79a+, CD10-, BCL2+, BCL6+, IRF4/MUM1+, FOXP1+; translocations involving MYC, BCL6, and IGH genes are common
EBV-Positive Diffuse Large B-Cell Lymphoma of the Elderly: CD20+/-, CD79a+/-, CD10-, IRF4/MUM1+/-,
BCL6-, LMP+, EBER+
DLBCL Associated With Chronic Inflammation: CD20+/-, CD79a+/-, CD138-/+, IRF4/MUM1-/+, CD30-/+, Tcells markers-/+, LMP+/-, EBER+/Lymphomatoid Granulomatosis: CD20+, CD30+/-, CD79a-/+, CD15-, LMP+/-, EBER+.
Primary Mediastinal (Thymic) Large B-Cell Lymphoma: sIG-/+, PanB+, (especially CD20, CD79a),
CD45+/-, CD15-, CD30-/+ (weak), IRF4/MUM1 +/-, BCL2+/-, BCL6+/-, CD23+, MAL+; IGH and IGL gene
rearrangements
Intravascular Large B-Cell Lymphoma: Pan B+ (CD19, CD20, CD22, CD79a), CD5-/+, CD10-/+,
IRF4/MUM1+
ALK-Positive Large B-Cell Lymphoma: ALK+, CD138+, EMA+, VS38+, CD45-/+, CD4-/+,
CD57-/+, CD20-, CD79a-, CD3-, CD30-/+, IRF4/MUM1-/+, t(2;17)(p23;q23)+/-, t(2;5)(p23;35)-/+
Plasmablastic Lymphoma: CD38+, CD138+, Vs38c+, IRF4/MUM1+, CD79a+/-, EMA +/-, CD30+/-, CD45-/+,
CD20-/+, PAX5-/+, EBER+/-, EMA+/-, CD30+/Large B-Cell Lymphoma Arising in HHV8-Associated Multicentric Castleman Disease: CD20+/-, CD79a-,
CD38-/+, CD138-, EBER-, lambda light chain restricted
Primary Effusion Lymphoma: CD45+/-, CD30+/-, CD38+/-, CD138+/-, EMA+/-, CD19-, CD20-, CD79a-,
CD3-/+, BCL6-, HHV8/KSHV+, EBV+/-, IGH and IGL gene rearrangements
Burkitt Lymphoma: sIGM+, PanB+, CD5-, CD10+, BCL6+, CD38+, CD77+, CD43+, CD23-; Ki-67 (95-100%),
BCL2-; TdT-, IGH and IGL gene rearrangements, t(8;14)(q24;q32) and variants t(2;8)(p12;q24) and
t(8;22)(q24;q11); rearranged MYC gene; EBV common (95%) in endemic cases and infrequent (15-20%)
in sporadic cases, intermediate incidence (30-40%) in HIV-positive cases
B-Cell Lymphoma, Unclassifiable, With Features Intermediate Between Diffuse Large B-cell Lymphoma
and Burkitt Lymphoma: PanB+, CD10+, BCL6+, BCL2-/+, IRF4/MUM1-, Ki-67 (50-100%), 8q24/MYC
translocation (35-50%), BCL2 translocation (15%), and occasionally both translocations (so called double
hit lymphoma)
B-Cell Lymphoma, Unclassifiable, With Features Intermediate Between Diffuse Large B-cell Lymphoma
and Classical Hodgkin Lymphoma: CD45+/-, CD20+/-, CD79a+/-, CD30+/-, CD15+/-, PAX-5+/-, OCT-2+/-,
BOB.1+/-, CD10-, ALKMature T-Cell and NK-Cell Neoplasms
T-Cell Prolymphocytic Leukemia: PanT+ (CD2, CD3, CD5, CD7), CD25-, CD4+/CD8->CD4+/CD8+>CD4/CD8-, TCL1+, TdT-, CD1a-; TCR gene rearrangements, 75% show inv 14 with breakpoints at q11 and q32,
10% have a reciprocal tandem translocation t(14;14)(q11;q32)
T-Cell Large Granular Lymphocytic Leukemia: PanT+ (CD2, CD3+, CD5+/-), CD7-, TCR+, CD4-, CD8+,
CD16+, CD56-, CD57+, CD25-, TIA1+, granzyme B+, TdT-; most cases show clonal TCR gene
rearrangements
Chronic Lymphoproliferative Disorder of NK Cells: sCD3-, cCD3+, CD16+, CD56 (weak), TIA1+, granzyme
B+, CD8+/-, CD2-/+, CD7-/+, CD57-/+, EBV-, karyotype is typically normal
Aggressive NK-Cell Leukemia: CD2+, sCD3-, cCD3+, CD56+, TIA+/-, CD16+/-, CD57-, Fas ligand+, EBV+,
del(6)(q21q25) and del(11q) can be seen
Systemic EBV-Positive T-Cell Lymphoproliferative Disease of Childhood: CD2+, CD3+, TIA+, CD8+ (if
associated with acute EBV infection), EBER+, CD56-, TCR gene rearrangements+
Hydroa Vacciniforme-like Lymphoma: Cytotoxic T-cell or less often CD56+ NK-cell phenotype, EBER+/-,
TCR gene rearrangement+
Adult T-Cell Leukemia/Lymphoma (HTLV1+): PanT+ (CD2+, CD3+, CD5+), CD7-, CD4+, CD8-, CD10+,
CD25+, TdT-; TCR gene rearrangements, clonally integrated HTLV1
Extranodal NK/T-Cell Lymphoma: CD2+, CD5-/+, CD7-/+, CD3-/+, granzyme B+, TIA1+, CD4-, CD8-,
CD56+/-, TdT-; usually no TCR or Ig gene rearrangements; usually EBV positive
Enteropathy-associated T-cell Lymphoma: CD3+, CD7+, CD4-, CD8-/+, CD103+, TdTHepatosplenic T-cell Lymphoma: CD2+, CD3+, TCR gamma-delta+, TCR alpha-beta rarely +, CD5-,
CD7+, CD4-, CD8-/+, CD56+/-, CD25-; TCRG gene rearrangements +/-, variable TCRB gene
rearrangements -/+; isochromosome 7q and trisomy 8 common
Subcutaneous Panniculitis-like T-Cell Lymphoma: CD8+, granzyme B+, TIA1+, perforin+, TCR alpha/
beta +, CD4-, CD56Lymphomatoid Papulosis: CD4+, CD2-/+, CD3+, CD5-/+, TIA1+, granzyme B+/-, CD30+/-; TCR gene
rearrangements+/-
Primary Cutaneous Anaplastic Large-Cell Lymphoma: CD4+, TIA1+/-, granzyme B+/-, perforin+/-, CD30+,
CD2-/+, CD5-/+, CD3-/+, CLA+, ALK-, EMA-/+; TCR gene rearrangements+/Primary Cutaneous Gamma-Delta T-Cell Lymphoma: TCR gamma/delta+, CD2+, CD3+, CD5-, CD56+,
CD7+/-, CD4-, CD8-/+, Beta F1Primary Cutaneous CD8-positive Aggressive Epidermotropic Cytotoxic T-cell Lymphoma: CD3+, CD8+,
granzyme B+, perforin+, TIA1+, CD45RA+/-, CD2-/+, CD4-, CD5-, CD7-, EBV-, Beta F1+; TCR gene
rearrangements (alpha/beta)+
Primary Cutaneous CD4-Positive Small/Medium T-Cell Lymphoma: CD3+, CD4+, CD8-, CD30-, TCR gene
rearrangements+
Peripheral T-Cell Lymphoma, NOS: PanT variable (CD2+/-, CD3+/-, CD5-/+, CD7-/+), most cases CD4+,
some cases CD8+, a few cases are CD4-/CD8-, or CD4+/CD8+; TCR gene rearrangements+
Angioimmunoblastic T-Cell Lymphoma: PanT+ (often with variable loss of some PanT antigens), usually
CD4+, PD1+, CXCL13+; TCR gene rearrangements in 75%; IGH gene rearrangements in up to 30%, EBV
often positive in B-cells
Anaplastic Large Cell Lymphoma, ALK Positive: CD30+, ALK+, EMA+/-, CD3-/+, CD2+/-, CD4+/-, CD5+/-,
CD8-/+, CD43+/-, CD25+, CD45+/-, CD45RO+/-, TIA1+/-, granzyme+/-, perforin+/-, EBV-, TCR gene
rearrangements+/-, t(2;5)(p23;35) in 80% of cases, t(1;2)(q25;p23) in 10-15% of cases. Other various
translocations can also be seen.
Anaplastic Large Cell Lymphoma, ALK Negative: CD30+ (strong/intense staining),
CD2+/-, CD3+/-, CD5-/+, CD4+/-, CD8-/+, CD43+, TIA1+/-, granzyme B+/-, perforin +/-, ALK-, TCR gene
rearrangements+
Histiocytic Sarcoma: CD45+, CD163+, CD68+, lysozyme+, CD45RO+/-, HLA-DR+/-, CD4+/-, S100-/+,
CD1a-, CD21-, CD35-, CD13, CD33, myeloperoxidase-, lack IGH and TCR gene rearrangements
Langerhans Cell Histiocytosis: CD1a+, langerin+, S100+, vimentin+, CD68+, HLA-DR+, CD4-/+, CD30+,
most B- and T-cell markers are negative, there are no consistent cytogenetic abnormalities
Langerhans Cell Sarcoma: CD1a+, langerin+, S100+, vimentin+, CD68+, HLA-DR+, CD4-/+, CD30+, most
B- and T-cell markers are negative, there are no consistent cytogenetic abnormalities
Interdigitating Dendritic Cell Sarcoma: S100+, vimentin+, CD1a-, langerin-, CD45+/-, CD68+/-,
lysozyme+/-, p53+/-, CD21-, CD23-, CD35-, CD34-, CD30-, myeloperoxidase-, most B and T-cell markers
are negative, lack IGH and TCR gene rearrangements
Follicular Dendritic Cell Sarcoma: Clusterin+, CD21+, CD35+, CD23+, KiM4p+, desmoplakin+, vimentin+,
fascin+, EDGR+, HLA-DR+, CD1a-, myeloperoxidase-, lysozyme-, CD34-, CD30-, CD3-, CD79a-, lack IGH
and TCR gene rearrangements
Disseminated Juvenile Xanthogranuloma: vimentin+, CD14+, CD68+, CD163+, factor XIIIa+/-, fascin+/-,
S100-/+, CD1a-, langerin-, lack IGH and TCR gene rearrangements
F. Clinical Prognostic Factors and Indices
The specific histologic type of the lymphoid neoplasm, stage of disease, as well as the International
13,21,28-33
Prognostic Index (IPI score) are the main factors used to determine treatment in adults.
The 5
pretreatment characteristics that have been shown to be independently statistically significant are: age
in years (≤60 versus >60); tumor stage I or II (localized) versus III or IV (advanced); number of extranodal
sites of involvement (0 or 1 versus >1); patient’s performance status (0 or 1 versus 2 to 4); and serum LDH
(normal versus abnormal). Based on the number of risk factors, patients can be assigned to 1 of 4 risks
groups: low (0 or 1), low intermediate (2), high intermediate (3), or high (4 or 5). Patients stratified by the
number of risk factors were found to have very different outcomes with regard to complete response
13
(CR), relapse-free survival (RFS), and overall survival (OS). Studies show that low-risk patients had an
87% CR rate and an OS rate of 73% at 5 years compared to high-risk patients who had a 44% CR rate
13
and a 26% 5-year overall survival rate. A revised IPI (R-IPI) has been proposed for patients with diffuse
34
large B-cell lymphoma who are treated with rituximab plus CHOP chemotherapy.
In pediatric cases,
16
there is no equivalent of the IPI, and prognosis is based on stage and type of lymphoma.
A separate prognostic index has become accepted for follicular lymphoma. The Follicular Lymphoma
International Prognostic Index (FLIPI) appears to provide greater discrimination and stratification among
35
patients with follicular lymphoma. It evaluates 5 adverse prognostic risk factors including age (>60
years versus ≤60 years), Ann Arbor stage (III to IV versus I to II), hemoglobin level (<120 g/L versus ≥120
g/L), number of nodal areas (>4 versus ≤4) and serum LDH level (above normal level versus normal or
below). Patients are stratified into 3 risk groups: low risk (0-1 adverse factors), intermediate (2 adverse
factors) and poor risk (≥3 adverse factors).
Prognostic indices are also under development in other lymphoid neoplasms such as mantle cell
lymphoma and T-cell lymphomas.
Although not always provided to the pathologist by the physician submitting the specimen, certain
specific clinical findings are known to be of prognostic value in all stages of NHL. In particular, systemic
symptoms of fever (greater than 38°C), unexplained weight loss (more than 10% body weight) in the
6 months before diagnosis, and drenching night sweats are used to define 2 categories for each stage
of NHL: A (symptoms absent) and B (symptoms present). The presence of B symptoms is known to
correlate with extent of disease (stage and tumor bulk), but symptoms also have been shown to have
6,28-33,36
prognostic significance for cause-specific survival that is independent of stage.
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18
Protocol for the Examination of Specimens from Patients
with Hodgkin Lymphoma
Protocol applies to Hodgkin lymphoma involving any site. #
Procedures
 Biopsy
 Resection of Lymph Node(s) or Other Organ(s)
Authors
Daniel A. Arber, MD
Stanford University School of Medicine, Stanford, California
Emory University Hospital, Atlanta, Georgia
Yellowstone Pathology Institute Inc, Billings, Montana
The Methodist Hospital, Houston, Texas
Physicians Laboratory Ltd, Sioux Falls, South Dakota
Flinders Medical Centre, Bedford Park, South Australia
University of New Mexico, Albuquerque, New Mexico
Cleveland Clinic Foundation, Cleveland, Ohio
Elaine S. Jaffe, MD
National Cancer Institute, Bethesda, Maryland
Presbyterian Pathology Group, Charlotte, North Carolina
University of Utah Health Sciences Center, Salt Lake City, Utah
*denotes the primary and senior author. All other contributing authors are listed alphabetically.
© 2009 College of American Pathologists (CAP). All rights reserved.
A. Specimen
Any number of specimen types may be submitted in the evaluation of Hodgkin lymphoma.
Lymph nodes, mediastinal masses, bone marrow, spleen, lung, and liver are among the most
common. Specimens submitted with a suspected diagnosis of Hodgkin lymphoma require
special handling in order to optimize the diagnosis. Often, lymph node specimens are submitted
19
where the differential diagnosis includes both Hodgkin and non-Hodgkin lymphomas, and, if
possible, tissue should be obtained for possible molecular and other ancillary studies, which are
often necessary for the diagnosis of non-Hodgkin lymphomas.1,2 Most flow cytometry,
molecular, and cytogenetic studies will not aid in the diagnosis of Hodgkin lymphoma.
Immunophenotyping by immunohistochemical staining is necessary in the initial diagnosis of
nearly all cases of Hodgkin lymphoma. Because of this, well-fixed sections are of paramount
importance. The guidelines detailed below are suggested for specimen handling in cases of
suspected Hodgkin lymphoma.
 Tissue should be received fresh. Unsectioned lymph nodes should not be immersed
in fixative, and care should be taken to make thin (2 mm) slices perpendicular to the long
axis of the node to ensure optimal penetration of fixative.
 The fresh specimen size, color, and consistency should be recorded, as should the
presence or absence of any visible nodularity, hemorrhage, or necrosis.
 Touch imprints may be made from the freshly cut surface, and the imprints fixed in alcohol
or air dried. Unstained air-dried imprints can be used for fluorescence in situ hybridization
(FISH) or other studies if necessary.
 For microbiology studies: submit a fresh portion of the lymph node (or other specimen type)
sterilely in appropriate medium.
 Flow cytometry immunophenotyping is not routinely used in the diagnosis of Hodgkin
lymphoma, but if the differential diagnosis includes non-Hodgkin lymphoma, a fresh portion
of the specimen should be submitted in appropriate transport medium such as RPMI.
 Fixation (record fixative[s] used for individual slices of the specimen):
o Estimated time from excision to fixation should be noted, if possible, as this may impact
preservation or recovery of certain analytes such as RNA and phosphoproteins in fixed
tissues.
o Zinc formalin or B+ produces superior cytologic detail but is not suitable for DNA
extraction and may impair some immunostains (eg, CD30). B+ also has the additional
limitation of requiring proper hazardous materials disposal.
o Formalin fixation is preferable when the tissue sample is limited, as it is most suitable for
immunohistochemistry as well as many other ancillary tests such as molecular/genetic
studies and in-situ hybridization.
o Over-fixation (ie, more than 24 hours in formalin, more than 4 hours in zinc formalin or
B+) should be avoided for optimal immunophenotypic reactivity.
B.
Tumor Site
Hodgkin lymphomas are nearly always nodal based with cervical lymph nodes more commonly
involved. It can also frequently be seen involving mediastinal, axillary, and paraaortic lymph
nodes. Extranodal Hodgkin lymphoma can rarely be seen. The anatomic distribution of
Hodgkin lymphoma, however, varies depending on the histologic type.3
C.
Histologic Type
This protocol recommends assigning histologic type based on the World Health Organization
(WHO) classification of lymphoid neoplasms.4 It was originally published in 2001 and more
recently revised and updated in 2008.4,5 This classification encompasses both Hodgkin and
non-Hodgkin lymphomas and allows distinction of individual lymphoid neoplasms based upon
morphologic, immunophenotypic, cytogenetic, and clinical features. While histologic
examination typically is thought to be the gold standard, the majority of Hodgkin lymphomas will
require immunohistochemical staining, especially at the time of initial diagnoses.4-9 In addition,
while Hodgkin lymphomas are currently divided into nodular lymphocyte predominant Hodgkin
lymphoma and classical Hodgkin lymphomas (including nodular sclerosis, mixed cellularity,
20
lymphocyte-rich, and lymphocyte-depleted subtypes), it should be recognized that classical
Hodgkin lymphomas may not represent a single disease. In addition, there is overlap between
some cases of Hodgkin lymphoma and non-Hodgkin lymphoma, particularly diffuse large B-cell
lymphomas (so-called gray zone lymphomas).4,10
D.
Pathologic Extent of Tumor (Stage)
The TNM classification is not used for staging Hodgkin lymphomas because the site of origin of
the tumor is often unclear and there is no way to differentiate among T, N, and M. The Cotswold
revision of the Ann Arbor staging classification is used for Hodgkin lymphoma.11,12 It was
originally published over 30 years ago.
Pathologic staging depends on the biopsy of multiple lymph nodes on both sides of the
diaphragm, splenectomy, wedge liver biopsy, and bone marrow biopsy to assess distribution of
disease.
Currently, staging for Hodgkin lymphoma is more commonly clinical than pathologic. Clinical
staging generally involves a combination of clinical, radiologic, and surgical data. Physical
examination, laboratory tests, imaging studies (eg, computed tomography [CT] scans, magnetic
resonance imaging [MRI] studies, and positron emission tomography [PET]), biopsy (to
determine diagnosis, histologic type, and extent of disease), and bone marrow examination are
often required. Correct diagnosis and staging are the key factors in providing appropriate
treatment.13-15
Cotswold Revision of the Ann Arbor Staging Classification of Hodgkin
Lymphomas13,14
Stage I
Stage II
Stage III
Stage IV
Involvement of a single lymph node region (I), or lymphoid structure (eg, spleen,
thymus, Waldeyer’s ring).#
Involvement of 2 or more lymph node regions on the same side of the diaphragm
(II) (the mediastinum is considered a single site). ##
Involvement of lymph node regions on both sides of the diaphragm (III) which
may be accompanied by extralymphatic extension in association with lymph node
involvement (IIIE) or splenic involvement (IIIS).
Involvement of extranodal site(s) beyond those designated E.
#
Multifocal involvement of a single extralymphatic organ is classified as stage IE and not stage
IV.
##
The number of lymph node regions involved may be indicated by a subscript: eg, II3.
E designates involvement of a single extranodal site or contiguous or proximal known nodal site
of disease.
E. Immunophenotyping
Immunophenotyping by flow cytometry and molecular testing by polymerase chain reaction
(PCR) are currently not typically used or are not necessary for the diagnosis of Hodgkin
lymphoma. Immunophenotyping using immunohistochemistry is necessary for the initial
diagnosis of nearly all cases of Hodgkin lymphoma. It requires well-fixed tissue sections for
optimal immunohistochemical staining and interpretation.
21
Immunophenotypes1,4-8
The following is to be used as a guideline for the more common immunophenotype for each
subtype of Hodgkin lymphoma. It is however, not entirely comprehensive and individual cases
may vary somewhat in their immunophenotypic profile.
Nodular lymphocyte predominant Hodgkin lymphoma: Lymphocyte predominant cells (LP cells;
previously called L&H cells) are CD20+, CD79a+, PAX5+, CD45+, BCL6+, OCT-2+, BOB.1+,
EMA +/-, CD15-, CD30-, CD43-, EBER-.
Nodular sclerosis classical Hodgkin lymphoma: Classical Hodgkin/Reed-Sternberg cells are
CD30+, CD15+/-, CD45-, PAX5+/-, CD20-/+, CD79a-/+, EBER-/+, OCT-2-/+,
BOB.1-/+, EMAMixed cellularity classical Hodgkin lymphoma: Classical Hodgkin/Reed-Sternberg cells are
CD30+, CD15+/-, CD45-, PAX5+/-, CD20-/+, CD79a-/+, EBER+/-, OCT-2-/+,
BOB.1-/+, EMALymphocyte-rich classical Hodgkin lymphoma: Classical Hodgkin/Reed-Sternberg cells are
CD30+, CD15+/-, CD45-, PAX5+/-, CD20-/+, CD79a-/+, EBER-/+, OCT-2-/+,
BOB.1-/+, EMALymphocyte-depleted classical Hodgkin lymphoma: Classical Hodgkin/Reed-Sternberg cells are
CD30+, CD15+/-, CD45-, PAX5+/-, CD20-/+, CD79a-/+, EBER+/-, OCT-2-/+, BOB.1-/+, EMA-
F.
Clinical Prognostic Factors and Indices
The International Prognostic Score (IPS) was developed for Hodgkin lymphoma to predict
outcome based on the following adverse factors: serum albumin <4g/dL, hemoglobin
concentration <10.5 g/dL, male sex, age ≥45 years, stage IV disease, white blood cell count
≥15,000/mm3, and lymphopenia <600/mm3 or <8%. The rate of freedom from progression by
risk category is: 0 factors 84%, 1 factor 77%, 2 factors 67%, 3 factors 60%, 4 factors 51%, and
5 or more factors 42%.13
Although not always provided to the pathologist by the physician submitting the specimen,
certain clinical findings are known to be of prognostic value in all stages of Hodgkin and nonHodgkin lymphoma. In particular, systemic symptoms of fever (greater than 38C), unexplained
weight loss (more than 10% body weight) in the 6 months before diagnosis, and drenching night
sweats are used to define 2 categories for each stage of lymphoma: A (symptoms absent) and
B (symptoms present). The presence of B symptoms is known to correlate with extent of
disease (stage and tumor bulk), but symptoms also have been shown to have prognostic
significance for cause-specific survival that is independent of stage.13 In addition to the IPS,
other prognostic factors, including HIV status, Bcl-2 expression, and pretreatment interleukin-10
serum levels, may be important. 18-21
1.
2.
References
Knowles D, ed. Neoplastic Hematopathology. Philadelphia, PA: Lippincott Williams and
Wilkins; 2001.
Mills S, ed. Histology for Pathologists. Philadelphia, PA: Lippincott Williams and Wilkins;
2007.
22
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
Shimabukuro-Vornhagen A, Haverkamp H, Engert A, et al. Lymphocyte-rich classical
Hodgkin’s lymphoma: clinical presentation and treatment outcome in 100 patients treated
within German Hodgkin’s Study Group trials. J Clin Oncol. 2005; 23(24):5739-5745.
Swerdlow S, Campo E, Harris N, Jaffe E, Pilero S, Stein H, Thiele J, Vardiman J, eds.
WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. Geneva,
Switzerland: WHO Press; 2008.
Jaffe ES, Harris NL, Stein H, Vardiman JW, eds. Pathology and Genetics of Tumours of
Haematopoietic and Lymphoid Tissues. Lyon, France: IARC Press; 2001. World Health
Organization Classification of Tumours, Vol. 3.
Hsi E, Goldblum J, eds. Hematopathology. Philadelphia, PA: Churchill Livingstone
Elsevier; 2007.
Zukerberg L, Collins AB, Ferry JA, Harris NL. Coexpression of CD15 and CD20 by ReedSternberg cells in Hodgkin’s disease. Am J Pathol. 1991; 139(3):475-483.
Jaffe E, Banks P, Nathwani B, et al. Recommendations for the reporting of lymphoid
neoplasms: a report from the Association of Directors of Anatomic and Surgical Pathology.
Mod Pathol. 2004; 17(1):131-135.
Stein H, Marafioti T, Foss H, et al. Down-regulation of BOB.1/OBF.1 and Oct2 in classical
Hodgkin disease but not in lymphocyte predominant Hodgkin disease correlates with
immunoglobulin transcription. Blood. 2001; 97(2):496-501.
Mani H, Jaffe E. Hodgkin lymphoma: an update on its biology with new insights into
classification. Clin Lymphoma Myeloma. 2009; 9(3):206-216.
Carbone P, Kaplan H, Musshoff K, et al. Report of the Committee on Hodgkin’s Disease
Staging Classification. Cancer Res. 1971; 31(11):1860-1861.
Lister T, Crowther D, Sutcliffe S, et al. Report of a committee convened to discuss the
evaluation and staging of patient’s with Hodgkin’s disease: Cotswolds meeting. J Clin
Oncol. 1989;7(11):1630-1636.
Lymphoid neoplasms. In: Edge SB, Byrd DR, Carducci MA, Compton CC, eds. AJCC
Cancer Staging Manual. 7th ed. New York, NY: Springer; 2009.
Sobin LH, Gospodarowicz M, Wittekind Ch, eds. UICC TNM Classification of Malignant
Tumours. 7th ed. New York, NY: Wiley-Liss; in press.
Kwee T, Kwee R, Nievelstein R. Imaging in staging malignant lymphoma: a systematic
review. Blood. 2008; 111(2):504-516.
Hasenclever D, Diehl V. A prognostic score for advanced Hodgkin’s disease: International
Prognostic Factors Project on Advanced Hodgkin’s Disease. N Engl J Med. 1998;
339(21):1506-1514.
Allemani C, Sant M, De Angelis R, et al. Hodgkin disease survival in Europe and the U.S.:
prognostic significance of morphologic groups. Cancer. 2006; 107(2):352-360.
Vassilakopoulos T, Angelopoulou M, Siakantaris M, et al. Prognostic factors in advanced
stage Hodgkin’s lymphoma: the significance of the number of involved anatomic sites. Eur
J Haematol. 2001; 67(5-6):279-288.
Sup J, Alemany C, Pohlman B, et al. Expression of bcl-2 in classical Hodgkin’s lymphoma:
an independent predictor of poor outcome. J Clin Oncol. 2005;23(16):3773-3779.
Rautert R, Schinkothe T, Franklin J, et al. Elevated pretreatment interleukin-10 serum level
is an International Prognostic Score (IPS)-independent risk factor for early treatment failure
in advanced stage Hodgkin lymphoma. Leuk Lymphoma. 2008; 49(11):2091-2098.
Rassidakis G, Medeiros LJ, Vassilakopoulos T, et al. Bcl-2 expression in Hodgkin and
Reed-Sternberg cells of classical Hodgkin lymphoma predicts a poorer prognosis in
patients treated with AVBD or equivalent regimens. Blood. 2002; 100(12):3935-3941.
23
Immunohistochemistry
Immunostains/In-Situ Hybridization Laboratory and Ordering
Information
Immunostain Turnaround Time
IHC Routine runs: All orders received before 10:00am should be sent out the same day by
5:30pm (i.e. Monday through Friday) provided the laboratory has the block (or slides). There
are a few stains (e.g. EBER, SV40, TdT, and antibody reactions on frozens) that require longer
incubations and these may be delayed by one day. Orders received after 10:00am will be out
the following morning by the 8:30am courier.
The Immunohistochemistry Laboratory is located at the CLB and personnel can be reached at
647-7663.
A list of the antibodies we use most frequently and a complete list with codes are included in the
manual.
ORDERING OF IMMUNOSTAIN PANELS
It is strongly recommended that the Audix voicemail (412-803-3273) is utilized when ordering
stains in order to facilitate delivery to Hematopathology.
If ordering after hours, the stain panels must now be ordered as Stain/Process Group Protocols
(see separate list).
(Unlike a Histology Protocol, a Stain/Process Group Protocol will not write over stains that have
been previously ordered on the same part)
To order one of the protocols:
1. If you are ordering the panel using the “Accession Entry/Edit” or “Histology Entry/Edit”
activities:

Go to the Histology tab.

Select the part (and/or block) on which you wish to order the panel.

Then click on the “Run Stain/Process Group…” button.

Enter the abbreviation for the Protocol in the “Select Protocol” field on the “Run
Stain/Process Group Protocol” pop up window.

Hit tab (on your keyboard). Then hit Enter (on your keyboard) or click the OK button in the
“Run Stain/Process Group Protocol” pop up window.

2. If you are ordering the panel using the “Stain/Process and Block Edit” activity:
Select the part (and/or block) on which you wish to order the panel.

Click on the “Add Stain/Process…” button.

Clinical on the “Run Stain/Process Group…” button.

Enter the abbreviation for the Protocol in the “Select Protocol” field on the “Run
Stain/Process Group Protocol” pop up window.
Hit tab (on your keyboard). Then hit Enter (on your keyboard) or click the OK button in the
“Run Stain/Process Group Protocol” pop up window.

In the comment field enter” Please deliver to Hematopathology” – otherwise the slides may end
up in your mailbox!!
If you have any questions, please contact AP User Support via e-mail or at 647-9170
ORDERING EXPERIMENTAL STAINS (ANTIBODIES NOT YET IN COMPUTER)
If being done in the routine immunohistology laboratory, order under ABNKNC. Specify desired
stain in the comment of ABNKNC.
If being done in the in situ laboratory order 2 blanks (IBNKNC) and write in comment to sent to
insitu laboratory for_________.
Reporting of Immunostains/in-situ hybridization
The template should always be utilized and follows the general microscopic description.
Stains Frequently Used In Hematopathology: Codes and Reactivities
Here’s a list of markers that are used commonly on the Lymph Node Service and their secret
Client Server code-names. See also the Hematopathology worksheet since its best to order via
panels.
Antigen /
Marker
CD1a
CD2
CD3
CD4
CD5
C/S Codename
ACD1
ACD2
ACD3
ACD4
ACD5
CD7
CD8
CD10
(CALLA)
ACD7
ACD8
ACD10
CXCL-13
PD-1
CD15 (LeuM1)
CD20 (L26)
CD21
ACXCL13
APDT
ALEUM1
CD22
CD23
ACD22
ACD23
CD30 (Ki1/Ber-H2)
ACD30
CD31
CD33
CD34
ACD31
ACD33
ACD34
CD43
ACD43
CD45 (LCA)
CD45RA
(4KB5)
CD45RO
(UCHL-1)
CD56
ALCA
ACD45R
AL26
ACD21
AUCHL1
ACD56
Cell-type/s
Thymocytes, Langerhans Cells
T-cells, NK-cells
T-cells, NK-cells
T-cells, Macrophage
T-cells, SLL/CLL & Mantle cell
lymphoma, B-cell subset
T-cells, NK-cells
T-cells, NK-cells
Lymphoblasts, Follicular center
cells, Granulocytes, Some
epithelial cells/neoplasms,
Follicular T-cells
Follicular T helper cells
Follicular T helper cells
R-S cells, CMV-infected cells,
Some carcinomas
B-cells
Follicular dendritic cells, Some Bcells
B-cells
Follicular dendritic cells,
SLL/CLL, Normal mantle cells
R-S cells, Activated T & B-cells,
Some lymphomas, Embryonal
carcinoma
Endothelium
Myeloid
Blasts, Endothelium, Various
mesenchymal neoplasms
T-cells, Myeloid cells, B-cell
subset, SLL/CLL, Mantle cell
lymphoma, Other B-cell
lymphomas, Not most follicular
lymphomas
All leukocytes
B-cells, Plasmacytoid dendulic
cells
T-cells, Macrophages
NK-cells, “NK-like” T-cells; Some
malignant myeloblasts,
lymphoblasts & plasma cells
(multiple myeloma)
Comment
CD57 (Leu
7)
CD61
CD68
ALEU7
CD79a
CD99
CD138
ACD79
AEWING
ACD138
Alk-1
AALK
TIA-1
ATIA
Granzyme B
Clusterin
AGRANZ
ACLUST
Bcl-2
ABCL2
Cyclin-D1
(bcl-1)
ACYCLD
Bcl-6
ABCL6
Ki-67 (MIB1)
TdT(Termina
ldeoxynucleo
tidyl
Transferase)
MPO
(Myeloperoxi
dase)
Tryptase
Neutrophil
Elastase
CD123
AKI67
Kappa light
chain
Lambda light
chain
J chain
ACD61B
ACD68
ATDT
NK-cells, Neural tissues, T-cell
subset in follicles
Megakaryocytes
Monocyte/Macrophage, Many
Melanomas!
B-cells
Blasts, Ewing Sarcoma
Plasma cells, R-S cells, Some
epithelial cells
Anaplastic large cell lymphoma
(systemic)
T-cells & NK-cells with cytolytic
granules
Cytotoxic T-cells and NK cells
Positive staining in anaplastic
large cell lymphomas
Many normal cells but NOT
NORMAL germinal center cells;
Majority of low grade follicular
lymphomas, fewer intermediate
grade ones; Many other
lymphomas
Mantle cell lymphoma, Some
multiple myelomas, Epithelial
cell/neoplasms
Germinal center B-cells (follicular
center cells); Many diffuse large
B-cell lymphomas
Proliferation marker (G1/S/G2/M
phases)
Lymphoblasts; Sometimes
myeloblasts (<20%)
AMPO
Myeloid cells
ATRYP
ANE
Mast cells
Neutrophils and their precursors
ACD123
Plasmacytoid dendritic cells,
some AML, HCL, basophils (at
least by flow cytometry)
AKAPPA
Ig light chain kappa
ALAMDA
Ig light chain lambda
AJ
J chain of IgA & IgM
Nuclear or nuclear and
cytoplasmic stain.
Granular cytoplasmic
stain
Cytoplasmic stain
(actually mitochondrial)
Nuclear stain (Don’t
call cytoplasmic stain
positive)
Nuclear stain
Nuclear stain
Used for blastic
plasmacytic dendritic
cell neoplasms (this is
WHO term),
mature PDC in CD,
necrot. lymphad, other
Beta-F1
ABF1
GlycophorinA
PAX5
EBV EBERISH
Kappa
mRNA-ISH
p27
AGLYP
Lambda
mRNA-ISH
Kappa/Lamb
da double
stain
Bartonella
henselae
stain
IRLAM
APAX5
IEBER
IRKAP
AP27
IKPLM
CABART
Beta-F1 T-cell receptor chain on
T-cells
RBC’s and their precursors
B-cells (nuclear stain)
Epstein-Barr Virus Encoded
mRNA (in situ hybridization)
Ig light chain kappa mRNA (in
situ hybridization)
Pos in indolent B-cell lymphomas
but not MCL
Ig light chain lambda mRNA (in
situ hybridization)
Kappa is black /Lambda is redorange (antibody stain performed
in in-situ hybridization lab)
Bartonella henselae
Order under Run
Stain/Process Group
Order under Run
Stain/Process Group
Order under Run
Stain/Process Group
Order under Run
Stain/Process Group
Complete Immunohistochemical Stain Abbreviations/Codes
See online library for detailed information re: clones, etc
https://www.medialabinc.net/lms/student/st_login.aspx?brandid=2 (See Hematopathology Dept
for Login)
Antibody
Actin - Smooth muscle (SMA)
Actin All Muscle
Adenovirus
Adhalin
Adrenocorticotropic Hormone
AE1
AE1/3
AE3
ALK-LUNG
Alpha 1 Antitrypsin
Alpha-Fetoprotein
Alzheimer beta Amyloid
Anaplastic Lymphoma Kinase
androgen receptor
Annexin-1
APP
B72.3/TAG Tumor Glycoprotein
Bartonella Henselae
Bcl-2 Oncoprotein
BCL6
BerEP4
Beta Catenin
BetaF1 T-cell Receptor
BHCG
BK Virus
BOB1
C1Q Complement
C4d
C5B-9 Membrane Complex
Test Code
AACTIN
AMA
Adenovirus
Adhalin
ACTH
AE1
AE1/3
AE3
ALK-LUNG
AAT
AFP
A4G8
AALK1
AAR
Annexin-1
APP
ATAG
Bhenselae
ABCL2
ABCL6
ABEREP4
ABCATN
ABF1
ABHCG
ABKV
ABOB1
AC1Q
AC4D
APMAC
CA125
CA19.9
CA9
Calcitonin
Caldesmon
Calponin
Calretinin
CAM 5.2
CD10 (CALLA)
CD117 C-KIT
CD138
CD15
CD1a
CD2
CD20 - L26
CD21
CD22
CD23
CD25 INTERLEUKIN2
CD3
CD30
CD31
CD33
CD34
CD4
CD4 Frozen
CD43
CD45RA
CD5
CD56
CD57
CD61
CD68
CD7
CD79a
ACA125
YCA199
ACA9
ACALCI
ACALDES
ACALP
ACALRET
CAM 5.2
ACD10
CD117
ACD138
ACD15
ACD1A
ACD2
CD20
CD21
CD22
CD23
ACD25
CD3
CD30
ACD31
CD33
CD34
CD4
CD4f
CD43
CD45RA
CD5
CD56
CD57
CD61
CD68
CD7
CD79a
CD8
CD99 - Ewing
CDX2
CEA
CEA-M
Chromogranin
CITED-1
CKIT - CD117
CLUSTERIN
c-MYC
c-MET
COLLAGEN IV
CRP
CXCL13
Cyclin D1 - BCL-1
Cytokeratin - Pan Keratin
Cytokeratin 19
Cytokeratin 20 - CK20
Cytokeratin 5
Cytokeratin 5/6 - CK5/6
Cytokeratin 7 - CK7
Cytokeratin AE1/AE3 - CK AE1/3
Cytomegalovirus
D2-40
Desmin
DOG1
Dysferlin
Dystrophin1
Dystrophin2
E-Cadherin
EGFR
EMA
Epstein Barr virus - EBV
ER
ERCC1
CD8
CD99
CDX2
ACEA
CEAM
ACHROMO
ACITED-1
ACKIT
ACLUST
MYC
c-MET (SP44)
ACOL4
CRP
CXCL 13
ACYCLD1
APANKLAM
ACK19
ACK20
CK5
ACK5/6
ACK7
AE1/3
ACMV
AD240
ADESMIN
DOG1
ADYSF
DYS1
DYS2
ECAD
AEGFR
AEMA
AEBV
AER
AERCC1
ERG
Ewing sarcoma - CD99
Factor 8 - vonWillebrand
Factor XIIIa
Fibrinogen
FLI1
Fmac
Follicle Stim. Hormone
Galectin-3
Gastrin
GATA-3
GCDFP15
Glial Fibrillary Acidic Protein - GFAP
Glucagon
Glut-1
Glutamine Synthetase
Glycophorin A
Glypican-3
Granzyme B
Growth Hormone
H. pylori
HBME-1
Hepatitis B Core
Hepatitis B Surface
HepPar 1 Hepatocytes
Her-2/neu c-erb
Herpes Simplex Virus I & II
HHV8
HMB45 Melanoma
HPV Papilloma Virus
HSP70
IBA1
IDH1
IgA
IgD
ERG
AEWING
AVWF
AXIII
FIBRINOGEN
FLI-1
AFMAC
FSH
Galectin-3
Gastrin
GATA3
AGCDFP
AGFAP
GLUC
AGLUT1
AGLUTSYNTH
AGLYP
GPC-3
AGRANZB
AGH
HPYL
AHBME
AHBCOR
AHBS
AHEPAR
ANEU
AHSV12
HHV8ip
AHMB45
AHPV
AHSP70
IBA1
IDH1
AIGA
AIGD
IgG
IgG4
IgM
IMP3
Inhibin Alpha
Insulin
Interleukin2 - CD25
J chain of IgA+IgM
Kappa Light Chain
KI67 Proliferating Cells
LAM/PANK
Lambda BM
Lambda Light Chain
Laminin
LCA, CD45 Monoclonal
LEF-1
Leu M1 - CD15
Lutenizing Hormone
Lysozyme
LYVE1
Mac 387 macrophage
Mammaglobin
MCPyV
Melan A/Melanoma
Merosin Frozen
MHC1
MITF
Mitochondrial
MLH1 Homolog
MOC-31
MSH2
MSH6
MUC-1
MUC-2
MUC-4
AIGG4
AIGG4
AIGM
IMP3
AINHIB
AINSU
ACD25
AJ
AKAPPA
Ki67
APANKLAM
LAMBDABM
ALAMBDA
ALAM
LCAMH
LEF-1
ACD15
ALH
ALYSO
LYVE1 BROWN
AMC387
AMAMA
MCPYV
MELANA
AMHC1
AMITFD
MITOC
MLH1
MOC31
MSH
AMSH6
AMUC1
AMUC2
AMUC4
MUC-5AC
MUC-6
MUM-1
Myelin Basic Protein (MBP)
Myeloperoxidase
Myogenin
Myoglobin
Myosin Heavy Chain
Napsin A
NEUN
Neurofilament
Neuron Specific Enolase
Neutrophil Elastase
NKIC3 melanoma
NKX3.1
OCT_2
OCT3/4
OPD4 (CD45RO)
P16
P21, WAF1
P27
P40
P501S
P504S
P53 Tumor Suppressor Protein
P63 Tumor Suppressor Protein
P75 NGF
P903
Pan Cytokeratin
Pancreatic Polypeptide
PANK (for PANK/LAM DS)
Parathyroid Hormone
Parvalbumin
Parvovirus
Pax-5, B-cell Specific Activator Protein
AMUC5AC
AMUC6
AMUM1
MBP
AMPO
AMYOGN
AMYO
ASMYOS
ANAPA
ANEUNUC
ANFIL
ANSE
ANEUNUC
ANKIC3
N/a
Oct_2
OCT3/4
AOPD4
AP16
AP21
AP27
n/a
P501S
AP504S
AP53
AP63
P75
AP903
CKPAN
APP
APANKLAM
APTH
APARV1
APARVO
APAX5
PAX-8
PAX8
PD1
PD1
PGP 9.5 Neuroendocrine
APFP
PIN4
APIN4
PLAP
PLAP
PMAC P5B
PMAC
PMS2
PMS2
Pneumocystis carinii
APCAR
PREA ATTR
ATTR
Progesterone Receptor
APR
Prolactin
APRO
Prostate Specific Acid Phosphatase
APAP
Prostatic Specific Antigen
APSA
PSTAT3
APSTAT
Renal Cell Carcinoma
ARCC
S100
AS100
Serotonin
ASERO
SDHB
SDHB
Smoothelin
SMOOTHELIN
Somatostatin
ASOMAT
SOX11
SOX11
Surfactant Protein A
ASPA
Synaptophysin
ASYNP
TAG-72
ATAG
TAU
TAU
TCL-1A
TCL-1A
Terminal Deoxynucleotide Transferase - TdT
TDT
TDP43
TDP-43
TFE3
TFE3
Thrombomodulin
ATHROMBO
Thyroglobulin
ATHYRO
TIA1 granzyme
ATIA1
Toxoplasma
ATOXO
Treponema pallidum
ATREP
Trypsin
TRYP
TRYPTASE
TSH
TTF-1
Tyrosinase
Ubiquitin
UCHL1 CD45RO
UP III
Varicella zoster
Vimentin
WT-1
TRYPTASE
ATSH
TTF1
ATYROS
AUBQ
AUCHL1
AUPIII
AVZV
AVIMEN
AMESO
CODES FOR DOUBLE LABELING
ICKDE
AE1/AE3 and desmin
ICKAC
AE1/AE3 and actin (HHF35)
ICKMI
AE1/AE3 and MIB-1
In all cases cytokeratin staining will be red (AEC) and the second antibody will be black (Nickel enhanced
DAB).
IKPLM
Kappa (black) and Lambda (red)
IBT
T-cell (CD3-black) and B-cell (L26/CD20-red)
IN-SITU HYBRIDIZATION PROBES AVAILABLE
Insitu (Brightfield)
iADV
iBKV
iCMV
iEBER
iHPV
i1618
i611
iHSV
iJCV
iRLAM
iRKAP
Adenovirus
BKV insitu
CMV insitu
EBER probe for EBV mRNA (Ventana)
HPV probe panel (manual method)
HPV 16,18,31,33,35,39,45,51,52,56,58,66 subtype (high)(Ventana)
HPV 6+11 subtype (low) (Ventana)
HSV probe
JC virus probe
mRNA for Lambda light chain restriction (Ventana)
mRNA for Kappa chain restriction (Ventana)
IHC testing in ISH Laboratory
aMIT
aPALABU
aBAPP
Mitochondrial antibody
Kidney
Neuropathology
IHC/ISH Reporting
Templates
PHS/B:______________________ Name:______________________
PARAFFIN SECTION IMMUNOHISTOCHEMISTRY/IN-SITU HYBRIDIZATION
In order to characterize ___________________, paraffin section immunohistologic/in-situ hybridization studies were performed on
___________________.
The following results were found:
Antigen/Antibody
Usual Reactivity
anti-kappa
B-cell subset
kappa mRNA-ISH
B-cell subset
anti-lambda
B-cell subset
lambda mRNA-ISH
B-cell subset
anti-IgG
B-cell subset
anti-IgG4
B-cell subset
anti-IgA
B-cell subset
anti-IgM
B-cell subset
anti-IgD
B-cell subset
CD20/L26
B-cells
CD19
B-cells
CD22
B-cells
CD79a
B-cells
PAX 5
B-cells
CD21
Follicular dendritic cells
CD35
Follicular dendritic cells
CD23
B-cell subset, follicular dendritic cells
CD138
Plasma cells, other
CD38
Activated cells, plasma cells
J chain
Plasma cells, other
BCL2
Lymphocyte subset, other
BCL2 E17
Lymphocyte subset, other
MYC
MYC protein
BCL6
Follicular center cells, other
CD10
B-cell subset
IRF4/MUM-1
B-cell subset
Cyclin D1
Mantle cell lymphoma, other
SOX-11
Mantle cell lymphoma, other
P27
Lymphoid subset
LEF-1/TCF-1
CLL/SLL, T-cells, other
Annexin A1
Hairy cell leukemia, myeloid, T cell
subset
TdT
Lymphoblasts, some myeloblasts
CD45/LCA
Leukocytes
CD15/Leu M1
Reed-Sternberg cells, myeloid
CD30/Ber H2
RS cells, activated lymphs
EMA
Epithelium, lymphocyte subset
OCT-2
B-cells, other
Bob.1
B-cells, other
ALK-1
Anaplastic large cell lymphoma kinase
Clusterin
ALCL, other
CD1a
Thymocytes, Langerhans-type cells
CD2
T and NK-cells
Result
CD3
T and NK-cells
CD4
T-helper/inducer cells
CD5
T-cells, B-cell subset
CD7
T and NK-cells
CD8
T-cytotoxic/suppressor cells
CD43/Leu 22
T-cells, some B-cells, myeloid
CD279/PD-1
T-follicular helper cells, other
CXCL13
T-follicular helper cells, other
Beta-F1
TCR-beta chain
Gamma TCR
TCR gamma
CD56
T-cell subset and NK-cells
CD57/Leu 7
T and NK cell subsets
TIA1
Cytotoxic cells
Granzyme B
Activated cytotoxic cells
CD25
Activated lymph, other
CD68/PGM-1
Myeloid, macrophages
Myeloperoxidase
Plasmacytoid dendritic cells,
Hairy cell leukemia, other
Plasmacytoid dendritic cells, T-PLL,
B-cell subset, other
Myeloid
Lysozyme
Myeloid, macrophages
CD14
Monocytic cells/macrophages
CD163
Monocytic cells/macrophages
CD33
Myeloid, macrophages, mast cells
Neutrophil elastase
Myeloid
CD117
Mast cells, myeloid precursors, other
Tryptase
Mast cells
CD34
Progenitor cells, endothelial cells, other
Glycophorin
Erythroid
E-cadherin
Immature erythroid, other
Factor VIIIRA
Megakaryocytes, endothelial cells
CD61
Megakaryocytes
Ki-67/MIB-1
Proliferating cells
P53
Tumor suppressor gene
AE1/AE3
Cytokeratin
Cam 5.2
Cytokeratin
Pankeratin
Cytokeratin
S100/S100a
Neural, melanoma & other
CD207/Langerin
Langerhans cells
EBV-ISH (EBER)
Epstein-Barr virus
EBV-LMP
Epstein-Barr virus
Parvovirus
Parvovirus
CMV
Cytomegalovirus
HHV8
H.Pylori
Human herpes virus-8
H. Pylori
B. henselae
Bartonella henselae
HSV 1/2
Human herpes viruses 1 & 2
CD123
TCL-1
Molecular Diagnostic and Cytogenetic Testing
MOLECULAR DIAGNOSTIC TEST ORDERING:
MOLECULAR DIAGNOSTICS WEBSITE:
http://path.upmc.edu/divisions/mdx/diagnostics.html



printable requisition form
information on required sample types for each test
frequently asked questions are answered
Request on BM specimens should be given to BM technologists – message can be left on the Audix line (8023273). On lymph node service, please fax requisition and save with fax “receipt” in notebook in room G323. It
is also preferred that you call to inform them a fax is coming. Lymph node assistant or backup should help.
The molecular oncology testing schedule (after DNA/RNA preparation) is as follows (updated 1/2012; subject
to change per MDX policy)
Monday/Thursday: TCR, IgH, JAK2, BCL-2 PCR testing is started and results out the next day
Wednesday: Quantitative BCR-ABL and Quantitative PML testing is started and results out Thursday or Friday
Wednesday: TCR, IgH, BCL-2 Southern blot testing is started and results out the following Tuesday
Please see below for example of requisition form.
Additional Testing Information: Specialty labs will do PCR for B. henselae from frozen specimens or
paraffin sections (test is not validated for paraffin sections). Their number is 800-421-7110, Pacific
Time, if you have specific questions. The samples should be sent through Molecular Diagnostics, as
for TB. Testing for Whipple disease can be arranged through the molecular diagnostics laboratory
also.
CYTOGENETICS TEST ORDERING: Please be sure that the pathology requisition is attached to the
cytogenetics requisition and that the cytogenetic requisitions have at least the following information:




Name of the patient and numerical identifier
Pathologist’s name
Clinician’s name (if clear on requisition not necessary to repeat)
Reason for sending specimen (“r/o lymphoma” should be fine for all of our specimens unless
you have different or more specific information to provide)
Please see below for example of cytogenetics requisition form as well as testing menu
PITTSBURGH CYTOGENETICS LABORATORY
Oncology Cytogenetic Study Requisition form
PATIENT INFORMATION (Please Print)
Last Name:
REFERRING PHYSICIAN (Please Print)
First:
M.I.:
Name:
Address:
Address:
City, State, Zip:
City, State, Zip:
Birthdate: ___________________
Sex: ______ Male
Female
Social Security #: ___________________
______
Telephone:
Medical Record #:
Account#:
Inpatient? _____ Location: _______________ Outpatient? _____
Fax:
Specimen information:
Date/Time of Collection: _______________ Amount Drawn: ________
Additional Report To:
Type of Specimen:
_____ Bone Marrow
_____ Peripheral Blood (unstimulated)*
_____ Tumor type (location)__________________________
_____ Lymph Node (location)_________________________
* Peripheral blood may be submitted for unstimulated studies only if
circulating blast count is above 5%.
Address:
____Pre-Bone Marrow Transplant
Female
____ Post-Bone Marrow Transplant
Sex of Donor: ____Male
City, State, Zip:
Phone:
Fax:
Clinical History/Pertinent Physical Findings (include
chemotheraphy and radiation therapy dates/drugs):
____
#days _____
Signature of Requesting Physician (REQUIRED!):
INDICATION FOR STUDY: (MUST BE COMPLETED!) * CIRCLE ALL THAT APPLY *
Anemia
Thrombocytopenia
Diagnosis: Tentative
Leukocytosis
Confirmed
Leukopenia
New Diagnosis?
CML: Chronic Phase Blast Phase
ALL: B-ALL
MDS
Other (Specify)
AML
Pancytopenia
T-ALL
Lymphoma
Remission Sample?
CLL
MM
Other (Specify)
Relapse Sample?
MPD (Specify)
TEST(S) REQUESTED: (MUST BE COMPLETED!) * CIRCLE ALL THAT APPLY *
Chromosome Analysis (Karyotype)
Yes
No
Fluorescence in-situ hybridization (FISH) panels requested:
MDS Panel
MPD Panel
AML Panel
* CIRCLE ALL THAT APPLY *
CLL Panel
MM Panel
FLUORESCENCE IN SITU HYBRIDIZATION (FISH)
Monosomy/Trisomy
Translocation/fusion
Children’s ALL
Panel
Break-apart rearrangement
B-Cell lymphoma
Panel
Solid tumors
___5q-
___BCR/ABL t(9;22)
___ALK (2p23)
___MLL (11q23)
___12CEP/12p
___Monosomy 7/ 7q-
___BIRC3/MALT t(11;18)
___AML1 (21q22)
___MYC (8q24)
___1p36/19q
___Trisomy 8
___CBFβ/MYH1 inv(16)
___BCL2 (18q21)
___PAX5 (9p13)
___ALK (2p23)
___Trisomy 9
___ETV6/RUNX1 t(12;21)
___BCL3 (19q13)
___PDGFRB (5q33)
___RARA (17q21)
___CHOP (12q13)
___Trisomy 12
___IGH@/FGFR3 t(4;14)
___BCL6 (3q27))
___TCF3 (19p13)
___TCL1 (14q32)
___ERBB2/CEP17
___13q-
___IGH@/BCL2 t(14;18)
___BCL10 (1p22)
___TCRAD (14q11)
___EWSR1 (22q12)
___20q-
___IGH@/CCND1 t(11;14)
___CCND1 (11q13)
___EVI1 (MECOM) (3q26)
___TCRB (7q34)
___FKHR(FOXO1)
(13q14)
___IGH@/MAF t(14;16)
___FGFR1 (8p12)
___TCRG (7p14)
___MONOSOMY 3
___IGH@/MALT1 t(14;18)
___IGH (14q32)
___TEL(ETV6) (12p13)
___N-MYC
___IGH@/MYC t(8;14)
___IGK (2p11)
___TLX1 (10q24)
___SYT (18q11.2)
___PML/RARA t(15;17)
___IGL (22q11)
___TLX3 (5q35)
___TLS(FUS) (16p11.2)
___Hyperdiploidy 5, 7, 9
___ATM (11q-)
___CMYB (6q-)
___P16(CDKN2A)
(9p21)
___P53 (del 17p13.1)
___MALT1 (18q21
PITTSBURGH CYTOGENETICS LABORATORY
Oncology Cytogenetic Study Requisition form
___RUNX1T1/RUNX1
t(8;21)
___PAX5 (del 9p13)
___XX/XY
___CHIC2/FIP1L1PDGFRA (4q12)
Others (Specify):_______________________________________________________________________________
Updated: 3/25/13 JH
Magee-Womens Hospital of UPMC
300 Halket St., Rm. 1225
(412)641-5558 PHONE (412)641-2255 FAX
Cytogenetics Test Menu
CYTOGENETICS
Break Apart Rearrangement Probes
ALK (2p23)
AML1 (21q22)
BCL2 (18q21)
BCL3 (19q13)
BCL6 (3q27)
BCL10 (1p22)
CBFB (16q22)
CCND1 (11q13)
ETV6 (TEL) (12p13)
EVI1 (MECOM) (3q26.2)
EWSR1 (22q11.2)
FGFR1 (8p12)
IGH (14q32)
IGK (2p11)
IGL (22q11)
MALT1 (18q21)
MLL (11q23)
MYC (8q24)
MYCN (2P23-24) (for amp)
PAX5 (9p13)
PDGFRB (5q33)
RARA (17q21)
TCRB (7q34)
TCRG (7p14)
TCRAD (14q11)
TCR3 (19p13)
TCL1(14q32.1)
Order Blanks - See Page One
Other
Translocation Probes
ASS deletion (9q34)
ATM deletion (11q22.3)
CEP X/Y
D7S486/CEP7 -7/7q31 I (7q)
(D7S522/CEP7) - 7/7q31
Deletion 13q (13q14) D135319
Deletion 20q (20q12) D205108
EGR1 -5/5q-
RUNX1T1/RUNX1 (ETO/AML1) t(8;21) AML
FIP1L1-CHIC2-PDGFRA(4q12) (CHIC2 deletion)
BIRC3-MALT1 (API2-MALT1) t(11;18)
CDKN2A (p16) (9p21 deletion)
TP53 deletion (17p13.1)
Trisomy 5, 9, 15
Trisomy 8 D8Z2
Trisomy 12 D1273
BCR-ABL t(9;22) CML/ALL/AML
IGH - CCND1 (T11:14)
IGH-BCL2 t(14;18)
CBFB-MYH1 (16p13/16q22) t(16;16). inv(16)
IGH-FGFR3 t(4;14)
IGH-MAF t(14;16)
IGH MALT1 t(14;18)
IGH-MYC t(8;14)
PML-RARA t(15;17)
TEL-AML1 (ETV6/RUNX1) t(12;21)
Panels
B-Cell Lymphoma - BCL6 (3q27) / MYC (8q24) / IGH (14q32.3) / BCL2 (18q21)
CLL - MYB (6q23) / ATM (11q22.3) / trisomy 12 / D13S319 (13q14.3) / IGH (14q32.3) / p53 (17p13.1)
Multiple Myeloma MM - D13S319 (13q14.3) / ATM (11q22.3) / p53 (17p13.1) / IGH (14q32.3) / CCND1 (11q13)
Childrens' ALL - CEP4/CEP10/CEP17 (trisomies 4, 10, 17) / BCR/ABL [t(9;22)] / MLL (11q23) / TEL-AML1 (ETV6/RUNX1) t((12;21)
Childrens' AML - EGR1 (5q31) / monosomy 7 / ETO-AML1 (RUNX1T1/RUNX1) [t(8;21)] / MLL (11q23) / CBFB [inv(16)]
MDS/AML - EGR1 (5q31) / D7S486 (7q31)-CEP7 / trisomy 8 / D2OS108 (20q12)
AML Panel - EGR1 (5q31) / D7Z1 - D7S486 / RUNX1T1-RUNX1[t(8;21)] / CBFB [inv(16) or t(16;16)] / MLL [t(11;var)]
[as needed (i.e. if not seen by classical analysis)]
MPD panel - BCR-ABL1 / CEP8 / CEP9 / D2OS108 (20q12)
Myeloid/lymphoid neoplasm with eosinophilia - FIP1L1-CHIC2-PDGFRA (4q12), PDGFRB (5q33), FGFR1 (8p13)
Additional FISH Probes Request (please list) Requested Ordered Blanks Sent
Comments
FISH panels for Hematologic Malignancies
CLL Panel
DNA Probe
1. D13S319/LAMP2
2. CEP 12
3. ATM
4. p53
5. CMYB
6. IGH
Chromosome Breakpoint
13q14.3
12p11.1-q11.1
11q22.3
17p13.1
6q23
14q32.3*
*If IGH is positive, we may recommend a few translocation probes involving 14q32
a. IGH/BCL2
t(14;18)(q32;q21)
b. IGH/CCND1 t(11;14)(q13;q32)
Multiple Myeloma (MM) Panel
DNA Probe
1. IGH
2. IGH/CCND1
3. TP53/CEP17
4. D13S319/LAMP1
5. D5S23/D5S721,9q34,CEP7
14q32.3
14q32/11q13
17p13.1
13q14.3
5p15.2, 9q34, 7p11.1-q11.1
(hyperdiploidy)
If IGH is + and IGH/CCND1 is -, then we will do FISH for:
 IGH/FGFR3
t(4;14)(p16;q32)
 IGH/MAF
t(14;16)(q32;q23)
If classical chromosome analysis is normal and the above MM FISH panel is negative, then the
following FISH will be performed reflexively:
ALL panel
DNA Probe
1. BCR/ABL
2. MLL
3. ETV6/RUNX1
(TEL/AML1)
4. CEP4
5. CEP10
6. CEP17
9q34/22q11.2
11q23
12p13/21q22
4p11-q11
10p11.1-q11.1
17p11.1-q11.1
B-Cell Lymphoma Panel
1.
2.
3.
4.
DNA Probe
BCL6
MYC
IGH
BCL2
3q27
8q24
14q32
18q21
MDS Panel
1.
2.
3.
4.
5.
DNA Probe
EGR1
CEP 7
D7S486
CEP 8
D20S108
5q31
7p11.1-q11.1
7q31
8p11.1-q11.1
20q12
MPD Panel
1.
2.
3.
4.
DNA Probe
BCR/ABL
CEP 8
CEP 9
D20S108
9q34/22q11.2
8p11.1-q11.1
9p11-q11
20q12
AML Panel
1.
2.
3.
4.
5.
DNA Probe
D7Z1/D7S486
EGR1
RUNX1T1/RUNX1
(ETO/AML1)
CBFB
MLL
7p11.1-q11.1/7q31
5q31/5p15.2
8q22/21q22
16q22 [inv(16)]
11q23
MALT Lymphoma Strategy
DNA Probe
1. MALT1
18q21*
*If MALT1 is positive, we will recommend a few translocation probes involving
18q21
a. IGH/MALT1
t(14;18)(q32;q21)
b. API2/MALT1 t(11;18)(q21;q21)
CML Strategy
ES probe
1. BCR/ABL ES
t(9;22)(q34;q11.2)*
*If the extra signal is not observed using the BCR/ABL ES DNA probe and the cells are
positive for the fusion signal in a considerable proportion of cells, perform FISH using the
LSI ASS (9q34) DNA probe to detect a deletion of 9q.
*If there is suspicion for the acute phase or blast phase of CML, we may suggest the
following FISHes to detect trisomy 8 and/or i(17q) using the following DNA probes:
a. CEP 8
b. RARA/CEP17
8p11.1-q11.1
17q21
CoPath and Dictation
Pointers
COPATH Related Instructions for Dictation of Final Reports
1. At time of dictating any report, the patient name, the CoPath pathology report number,
the medical record number should be stated in all instances except the occasional
consult in which this information is not available. With the exception of the other cases,
the number put in the dictaphone should be the MR number. At the end of the dictation,
state that this is the end of the dictation on ____________ (given patient’s name).
2. The trainee dictating at the end of the final diagnosis can state “do not mark this case
complete.” In this instance, the transcriptionist will not finalize the case by marking it
“complete” during the transcription process. If the report is dictated before noon, within
two hours it will be available for correction by the trainee. If it is dictated afternoon, four
hours later, the report will be available for corrections. In all instances, reports dictated
before the four o’clock cut-off would be transcribed on the same day. The trainee then
can go into the report and edit the final diagnosis and microscopic (as well as the gross
and clinical history they choose) and when finished they must mark the case as
“complete” which will then sent to the physician’s electronic sign-out queue. During this
process the trainee is to verify that the final diagnosis matches that written on the hard
copy during sign-out. If a report is not ready, contact the secretarial supervisor. The
trainee should then give the paperwork including a printed final copy to the staff
pathologist.
The trainee should ask the faculty person if the above is what they want. If not, be sure to
given the faculty person all paperwork.
3. All “UP” cases (white or yellow sheet consults) must have a billing code dictated. These
consult cases have either a white or yellow sheet on the folder containing the consult
case. Blue sheet consults (usually performed at request of clinician) do not need a
billing code dictated.
4. Cut off times:
 Cases dictated by 5:00 PM Monday – Friday will be typed that day
 Cases dictated after 5:00 PM Monday – Friday will be typed by 10:00 AM the
next day
 Saturday: cases dictated by 12 Noon will be typed that day
BILLING CODES FOR “UP” CASES (“WHITE” OR “YELLOW” SHEET CONSULTS)
BC#
Consultation Type
1
Level I Consult (very simple review, no extra stains)
2
Level II Consult (greater than 4 H&E, or up to 3 IHC stains)
3
Level III Consult (4-7 IHC stains)
4
Level IIII Consult (complex with 8-11 IHC stains)
5
Level V Consult (complex with ≥12 IHC stains)
6
Lymph Nodes with Flow Cytometry and No Immunostains
14
No Charge (including VA flows)
15
Stains, only
FLOW/IHC cases -- coded comments for discussion
Coded comments to add to end of microscopic description after immunostain table or if
there is no immunostain table (because it will be in an addendum) under “Ancillary
Studies.”
FLOW/IHC1: Medical necessity justification for the immunohistochemical stains that were
needed in addition to the flow cytometric immunophenotypic studies for the best diagnosis
possible is as follows: The flow cytometric studies did not define the precise nature of all the
cellular elements of concern in this specimen.
[to be used for example if a cyclin D1 stain with other markers is needed or if flow didn't
evaluate a plasma cell or possible RS population]
FLOW/IHC2: Medical necessity justification for the immunohistochemical stains that were
needed in addition to the flow cytometric immunophenotypic studies for the best diagnosis
possible is as follows: The flow cytometric studies are not clearly representative of all the
features requiring evaluation in this specimen.
[To be used for example if you have lymphoid aggregates in marrow that might not be in the
flow suspension, suspension was dilute]
Coded comment to add to end of flow report when it will precede the complete report
with the above coded comments:
FLOW1: Because these flow cytometric studies do not fully clarify the diagnosis in this case,
immunohistochemical stains will be performed on this specimen and a final report will follow.
Division of Hematopathology
Dictating & Proofing Tissue Reports*
(Suggestions for trainees)
Patient history:
 Look at prior cases in CoPath worksheet, outside reports, requisitions, MARS (if patient
is or has been at UPMC), letter (if consult) for historical information and be sure to
include in report since, in part, some or all of this information may be very hard to find at
a later date. This is OUR responsibility. For bone marrow cases, the technologists often
enter a clinical history, but it is up to us to verify the accuracy and completeness.

Be sure pre-op, post-op diagnoses and procedure have been entered.
Diagnosis:
 Be sure to use standard format
o Tissue type, tissue site, procedure (and if consult, Outside slide number “OSS….,
institution”)- diagnosis using terminology of WHO (if malignant)
 NEVER use “consistent with” in a diagnostic line. This is departmental policy.
 If more than one specimen on a consult, the different parts should be in chronological
order.
 Abbreviations should be avoided; if used in a report, the full term should be provided the
first time it is used.
Comment:
 Be sure that the comment includes the methods used to arrive at the diagnosis.
Phenotypic aberrancies that might be useful to follow up on in any subsequent
specimens are useful to include here. Ask the attending pathologist if there is any
question about what should be included in the comment.
 The comment should stress the major diagnosis first and must be consistent with the
diagnoses listed above (i.e.: it should not “back-track” on a definitive diagnosis).
 The comment does not necessarily have to follow the same order as the specimens
listed in the diagnosis (i.e., a definitive diagnosis might be dealt with first).
 Be sure at least the comment, if not the diagnosis, clearly indicates any studies still
pending at the time of signout. These should not come as a surprise to the physician
receiving the report.
Microscopic description
 Microscopic descriptions should “conjure up” and clearly convey an image that is
consistent with the diagnosis. “Buzz words” can be used to help achieve brevity and,
while it is best to avoid using descriptions to make conclusions, there is no need to
describe all the features of obviously reactive follicles or T-zone nodules.
 Microscopic descriptions in general should start with a statement concerning the tissue
type, the low magnification architectural features and then the relevant cytologic
features. Special stains should then follow and then the IHC/ISH template (if any such
stains have been performed).
 IHC tables should follow the part that has been described in multipart specimens –
easiest way so it’s clear what they refer to.
 Cases with flow cytometric studies and immunostains MUST HAVE a FLOW/IHC1 or 2
comment at the end of this section.


On consult cases with prior flow cytometric studies, the outside flow reports should at
least be summarized including a statement as to which laboratory did the studies. Place
after (or before) the IHC/ISH results.
On “UP” consult cases, be sure to dictate a billing code at the end. Cases with flow plus
just H&E sections get BC6. Our other UP cases with 4-7 special stains will be BC3,
more complex cases will be BC4 (8-11 special stains), with the most complex cases with
greater than 12 stains getting BC5.
Synoptic reports
 A synoptic should be added to all bone marrow and solid tissue reports when a
hematopathologic/lymphoid neoplasm is being diagnosed. Currently on the bone
marrows, these are being added on first-time diagnoses only, although they do not need
to be limited to those cases.
 There are currently four (4) synoptics used in Hematopathology.
o Bone Marrow/Peripheral Blood Hematopoietic/Lymphoid Disorders Synoptic
o Gastrointestinal Lymphoma Resection Synoptic
o Hodgkin Lymphoma Biopsy/Staging Synoptic
o Non-Hodgkin’s Lymphoma Biopsy/Resection Synoptic
 Synoptic reports may be dictated using the templates included this manual. A
hard copy is available in rooms G315 and G323. Alternatively, they can be manually
entered in CoPath after case dictation.

Instructions for the use of synoptics are available online. The CoPath user guide is
posted on the CoPathPlus website http://copath.upmc.com under the link for CoPathPlus
Training Resources. The Synoptic Data Entry and Reporting Chapter is Chapter 24.
Proofreading
 Proofread reports carefully and MAKE SURE that what is written not only is what was
intended at sign out but that it makes sense. If proofing prior to giving to a faculty
member and something doesn’t make sense, at least communicate that to them.
 Be sure to proof numbers that have been included (including in the flow reports)
 Be sure that immunostain designations are what you intended (i.e., sometimes
CD45RO/UCHL1 gets entered instead of CD45/LCA).
 Be sure singular/plural forms of words are correct, reports say “and” where you meant
“and” and not “in”, “intra-“and “inter-“are used appropriately.
 Be sure the templated tables don’t have capital letters in the middle of a sentence.
 Unless directed otherwise, give the faculty member a printed out final version of your
final report – not something with handwriting or a draft.
 Be sure to make an arrangement with the faculty member to see what changes were
made in what you considered to be a final report.
[Revised 10/2013]
Wording for Provisional Reports on Lymph Node Biopsies
Provisional reports may be when there is a delay in issuing a complete final report. These are
now a type of “special procedure”. These are to be used only on rare occasions.
When dictating the case, the transcriptionist must be instructed to type a provisional report.
Be sure the comment includes the following: This represents a provisional report. It will be
replaced by a final diagnostic report once…
Hematopathology Case Worksheet in CoPath
1.
2.
3.
4.
5.
Log into CoPath.
From the top menu bar, choose FILE.
Look in the Browse Items menu list. Scroll down until you get to HEME WORKSHEET.
Click and drag to your menu on the left so that this report will be available to you the next
time you log in.
6. Double click on HEME WORKSHEET. The report will take 1 minute to load.
7. Type the specimen number in the box under "Select a Specimen."
8. Click on ADD.
9. Run the report by clicking on OK.
10. Click on PRINT.
Resident/fellows can now review and print out the results of the special procedures that
have been signed out by following the directions given below. The print out will also
include the original diagnosis.
Special Procedure Review by Resident/Fellow in CoPath
1.
2.
3.
4.
Log into CoPath.
From the top menu bar, choose FILE.
Look in the Browse Items menu list. Scroll down until you get to PROCEDURE REVIEW BY
RESIDENT/FELLOW.
5. Click and drag to your menu on the left so that this report will be available to you the next
time you log in.
6. Double click on PROCEDURE BY RESIDENT/FELLOW.
7. Choose the data field criteria desired to run the report:
Typically for the data field:
 Choose the time range or date for Sign Out Date.
 For Specimen Class choose ALL VALUES
 For Procedure choose ALL VALUES
 For Person, click in the circle next to Individual Items, highlight the name of the
resident/fellow, then click on ADD. (You can add multiple names.)
8. Run the report by clicking OK.
9. The next time you log in to CoPath, you can just choose the PROCEDURE BY
RESIDENT/FELLOW report from your menu on the left and eliminate steps 2 to 5 above.
SYNOPTICS
Bone Marrow/Peripheral Blood Hematopoietic/Lymphoid Disorders
Synopti
Specimen #:
Part:
Patient:
Initials/Date:
- - - - - - - - - - - - - - - - MACROSCOPIC - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - MICROSCOPIC - - - - - - - - - - - - - - -
SPECIMEN TYPE/PROCEDURE**
(check all that apply)
W HO CLASSIFICATION** (check all that apply)
A1
Aspirate
A2
A3
A4
A5
A6
A7
Biopsy
Particle Preparation
Blood film
Cell block (Clot section)
Touch imprint
Not specified
B1
B2
B3
B4
B5
Right posterior iliac crest
Left posterior iliac crest
Other (specify):
Not specified
Note: This is NOT the final diagnosis. Use final diagno
/comment for therapeutic decisions.
D1
D2
D3
D4
D5
Myeloproliferative Neoplasms
Chronic myelogenous leukemia, BCR-ABL+
Chronic myelogenous leukemia, accelerated phase
Chronic myelogenous leukemia, myeloid blast crisis
Chronic myelogenous leukemia, lymphoid blast crisis
Chronic myelogenous leukemia, blast crisis, NOS
BIOPSY/ASPIRATE SITE**
D6
Chronic neutrophilic leukemia
Not applicable
D7
Chronic eosinophilic leukemia, NOS
D8
D9
D10
ADEQUACY OF SPECIMEN**
Mastocytosis
Cutaneous mastocytosis
Systemic mastocytosis
Systemic mastocytosis with associated clonal,
hematologic non-mast-cell lineage disease
Aggressive systemic mastocytosis
C1
Satisfactory
D11
C2
C3
Limited
Unsatisfactory
D12
D13
Mast cell leukemia
Mast cell sarcoma
C4
See report
D14
Extracutaneous mastocytoma
---W HO Classifications Continued on Next Page----
6.5
This is a worksheet. It is NOT the final diagnosis.
Synopti
Specimen #:
Part:
Patient:
Initials/Date:
W HO CLASSIFICATION (check all that apply) CONT'
D15
Polycythemia vera
D16
D17
D18
D19
D20
Primary myelofibrosis
Essential thrombocythemia
Myeloproliferative neoplasm, unclassifiable
Possible myeloproliferative neoplasm, see report
Favor myeloproliferative neoplasm but must rule out
other possibilities, see report
F1
F2
F3
F4
F5
F6
Refractory anemia
Refractory neutropenia
Refractory thrombocytopenia
Refractory anemia with ringed sideroblasts
Refractory cytopenia with multilineage dysplasia
Refractory cytopenia with multilineage dysplasia and
ringed sideroblasts
Myeloid and Lymphoid Neoplasms with Eosinophilia and
D21
D22
D23
E1
E2
E3
E4
E5
Abnormalities of PDGFRA, PDGFRB OR FGFR1
Myeloid and lymphoid neoplasms with PDGFRA
rearrangement
Myeloid neoplasms with PDGFRB rearrangement
Myeloid and lymphoid neoplasms with FGFR1
rearrangement
Myelodysplastic/ Myeloproliferative Neoplasms
Chronic myelomonocytic leukemia
Atypical chronic myeloid leukemia, BCR-ABLJuvenile myelomonocytic leukemia
Myelodysplastic/myeloproliferative neoplasm,
unclassifiable
Refractory anemia with ring sideroblasts associated
with marked thrombocytosis
F7
F8
Refractory anemia with excess blasts (RAEB)
RAEB-1
RAEB-2
F9
F10
Myelodysplastic syndrome, unclassifiable
Myelodysplastic syndrome associated with isolated
del(5q)
F11
F12
F13
F14
Childhood myelodysplastic syndrome
Refractory cytopenia of childhood
Possible myelodysplastic syndrome, see report
Favor myelodysplastic syndrome but must rule out
other possibilities, see report
F15
Myelodysplastic syndrome, classification pends
cytogenetics
6.5
Synopti
Specimen #:
Part:
Patient:
Initials/Date:
G1
G12
Acute Myeloid Leukemias (AML)
G13
Acute myeloid leukemia, not otherwise classified
Acute myeloid leukemia with recurrent genetic
abnormalities
G2
AML witH t(8;21)(q22;q22); RUNX1-RUNX1T1
G3
AML with inv(16)(p13.1q22) or t(16;16)(p13.1;q22);
CBFB-MYH11
Acute promyelocytic leukemia with t(15;17)(q22;q12);
PML-RARA
AML with t(9;11)(p22;q23); MLLT3-MLL
AML with t(6:9)(p23;q34); DEK-NUP214
AML with inv(3)(q21q26.2) or t(3;3)(q21;q26.2);
RPN1-EVI1
G4
G5
G6
G7
G8
G9
G10
AML (megakaryoblastic) with t(1:22)(p13;q13);
RBM15-MKL1
AML with mutated NPM1
AML with mutated CEBPA
Acute myeloid leukemia with myelodysplasia-related
changes
G11
AML with myelodysplasia - Following a
myelodysplastic syndrome or myelodysplastic
syndrome/myeloproliferative disorder
AML with myelodysplasia - Without antecedent
myelodysplastic syndrome
AML with myelodysplasia - With unknown prior
history
G14
G15
G16
G17
Therapy-related myeloid neoplasms
Therapy-related myeloid neoplasms c/w AML
Therapy-related myeloid neoplasms c/w MDS
Therapy-related myeloid neoplasms c/w MDS/MPN
Therapy-related myeloid neoplasm, NOS
G18
G19
G20
G21
G22
G23
Acute myeloid leukemia not otherwise categorized
AML with minimal differentiation
AML without maturation
AML with maturation
Acute myelomonocytic leukemia
Acute monoblastic and monocytic leukemia
Acute erythroid leukemia
G24
G25
G26
Acute megakaryoblastic leukemia
Acute basophilic leukemia
Acute panmyelosis with myelofibrosis
G27
Acute myeloid leukemia, final classification pends
cytogenetic studies
G28
Myeloid sarcoma
6.5
Synopti
Specimen #:
Part:
Patient:
Initials/Date:
H2
Myeloid proliferations related to Down syndrome
G29
G30
Transient abnormal myelopoiesis
Myeloid leukemia associated with Down syndrome
H3
H4
G31
H5
Acute leukemias of ambiguous lineage
G32
G33
G34
G35
G36
G37
G38
G39
G40
H1
Undifferentiated acute leukemia
Mixed phenotype acute leukemia with
t(9;22)(q34;q11.2); BCR-ABL1
Mixed phenotype acute leukemia with t(v;11q23);
MLL rearranged
Mixed phenotype acute leukemia, B/myeloid, NOS
Mixed phenotype acute leukemia, T/myeloid, NOS
Natural killer (NK) cell lymphoblastic
H6
leukemia/lymphoma
H10
Mixed phenotype acute leukemia, NOS
Bilineal acute leukemia
Biphenotypic acute leukemia
Acute leukemia, uncertain lineage
Precursor lymphoid neoplasms
B lymphoblastic leukemia/lymphoma, NOS
B lymphoblastic leukemia/lymphoma with recurrent
genetic abnormalities
B lymphoblastic leukemia/lymphoma with
t(9;22)(q34;q11.2); BCR-ABL1
B lymphoblastic leukemia/lymphoma with t(v;11q23);
MLL rearranged
t(12;21)(p13;q22) TEL-AML 1 (ETV6-RUNX1)
B lymphoblastic leukemia/lymphoblastic lymphoma
with hyperdiploidy
H7
B lymphoblastic leukemia/lymphoma with hypodiploidy
(hypodiploid ALL)
H8
t(5;14)(q31;q32) IL 3-IGH
t(1;19)(q23;p13.3); E2A-PBX1 (TCF3-PBX1)
B lymphoblastic leukemia/lymphoma, final
classification pends cytogenetic studies
H9
H11
T lymphoblastic leukemia/lymphoma
J1
J2
J3
B-cell lymphoid neoplasm, not further classified
Small B-cell lymphoid neoplasm, not further classified
Chronic lymphocytic leukemia/small lymphocytic
lymphoma
6.5
Synopti
Specimen #:
Part:
Patient:
Initials/Date:
J4
J5
Waldenstrom macroglogulinemia
J6
Heavy chain diseases
J7
J8
J9
J10
J11
J12
J13
Splenic marginal zone lymphoma
Hairy cell leukemia
Hairy cell leukemia-Variant
J14
J15
J16
J22
Plasma cell myeloma
Monoclonal gammopathy of undetermined significance
(MGUS)
Extraosseus plasmacytoma
Plasma cell neoplasm, not further categorized
Primary amyloidosis
Extranodal marginal zone lymphoma of
mucosa-associated lymphoid tissue (MALT-lymphoma)
J23
Pediatric nodal marginal zone lymphoma
J17
J18
J19
J20
J21
Follicular lymphoma
J24
J25
J26
J27
J28
J29
Follicular lymphoma, Grade not defined
Follicular lymphoma - Grade 1-2
Follicular lymphoma - Grade 3
Follicular lymphoma - Grade 3A
Follicular lymphoma - Grade 3B
Pediatric follicular lymphoma
J30
J31
J32
J33
J34
Primary Cutaneous DLBCL, leg type
J35
J36
J37
J38
J39
J40
J41
J42
J43
ALK positive large B-cell lymphoma
Large B-cell lymphoma arising in HHV8-associated
J44
Burkitt lymphoma
6.5
Synopti
Specimen #:
Part:
Patient:
Initials/Date:
J45
J46
K16
K17
K18
Primary Cutaneous gamma-delta T-cell lymphoma
Primary cutaneous CD8 positive aggressive
epidermotropic cytotoxic T-cell lymphoma
K19
Primary cutaneous CD4 positive small/medium T-cell
lymphoma
K20
K21
K22
K23
Anaplastic large cell lymphoma, ALK negative
Mature T-Cell and NK-Cell Neoplasms
K1
K2
K3
K4
K5
K6
Chronic lymphoproliferative disorder of NK-cells
Systemic EBV positive T-cell lymphoproliferative
disease of childhood
K7
K8
K9
K10
Extranodal NK/T-cell lymphoma, nasal-type
Enteropathy associated T-cell lymphoma
K11
K12
K13
K14
Mycosis fungoides
Sézary syndrome
Primary cutaneous CD30 positive T-cell
lymphoproliferative disorders
K15
Hodgkin Lymphoma
L1
L2
L3
L4
Nodular lymphocyte predominant Hodgkin lymphoma
Nodular sclerosis classical Hodgkin lymphoma
Lymphocyte-rich classical Hodgkin lymphoma
Mixed cellularity classical Hodgkin lymphoma
L5
L6
Lymphocyte-depleted classical Hodgkin lymphoma
Classical Hodgkin lymphoma, not further categorized
L7
Hodgkin vs non-Hodgkin lymphoma
M1
M2
M3
Histiocytic & Dendritic-Cell Neoplasms
Histiocytic sarcoma
Langerhans cell sarcoma
6.5
Synopti
Specimen #:
Part:
Patient:
Initials/Date:
Immunohistochemistry/In Situ Hybridization**
M4
M5
M6
M7
M8
Fibroblastic reticular cell tumor
Indeterminate dendritic cell tumor
Disseminated juvenile xanthogranuloma
R1
Immunohistochemistry/ in situ hybridization performed,
see microscopic description
R2
Immunohistochemistry/ in situ hybridization pending,
see addendum
Immunohistochemistry/ in situ hybridization not
performed
M9
Dendritic cell sarcoma, not otherwise specified
N1
Other
Malignant neoplasm, type cannot be determined
S2
Classical cytogenetic studies performed, see separate
report
Classical cytogenetic studies pending, report to follow
S3
Classical cytogenetic studies not performed
P1
P2
P3
P4
P5
Post-transplant lymphoproliferative disorders
Infectious mononucleosis-like PTLD
Polymorphic PTLD
Monomorphic PTLD (specify type):
Classical Hodgkin-lymphoma type PTLD
T1
Cytogenetic FISH studies performed, see separate
report
T2
Cytogenetic FISH studies pending, report to follow
T3
Cytogenetic FISH studies not performed
ANCILLARY STUDIES**
U1
Genotypic (Molecular) studies performed, see separate
report
Flow Cytometry-Phenotyping**
U2
Genotypic (Molecular) studies pending, report to follow
Flow cytometry immunophenotype performed, see
separate report
Flow cytometry immunophenotype pending, report to
follow
U3
U4
Genotypic (Molecular) studies not performed
DNA stored,Genotypic (Molecular) studies not
performed
U5
RNA stored,Genotypic (Molecular) studies not
performed
R3
Classical Cytogenetic Studies**
S1
Cytogenetic FISH Studies**
Genotypic (Molecular) Studies**
Q1
Q2
Q3
Flow cytometry immunophenotype not performed
6.5
Synopti
Specimen #:
Part:
Patient:
Initials/Date:
Cytochemical Stains**
V1
Cytochemical stains performed, see microscopic
description
V2
Cytochemical stains pending, see addendum
V3
Cytochemical stains not performed
ADDITIONAL PATHOLOGIC FINDINGS
Y1
Specify:
EXTENT OF BONE MARROW /PERIPHERAL BLOO
INVOLVEMENT
W1
Acute leukemia/MDS (bone marrow) % blasts W2
Acute leukemia/MDS (peripheral blood) - % blasts W3
Malignant lymphoma - approximately
% of area
involved
W4
W5
W6
Multiple myeloma
Plasma cells <10%
Plasma cells 10%-30%
Plasma cells >30%
OVERALL MARROW CELLULARITY**
X1
X3
X4
X5
X6
<10% X2
10-20%
21-40%
41-60%
61-80%
81-100%
X7
Variable, see report
X8
Not applicable
Comment:
6.5
Non-Hodgkins Lymphoma Biopsy/Resection Synoptic Template
Specimen #:
Part:
Patient:
Initials/Date:
- - - - - - - - - - - - - - - - MACROSCOPIC - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - MICROSCOPIC - - - - - - - - - - - - - - -
SPECIMEN TYPE**
HISTOLOGIC TYPE (W HO CLASSIFICATION)**
A1
A2
A3
Lymphadenectomy (specify sites):
Other (specify):
Not specified
A4
A5
Splenectomy
Other extranodal (specify):
B1
Fine needle aspiration
B2
B3
B4
B5
B6
Needle core biopsy
Biopsy, other
Resection
Other (specify):
Unknown
D1
Histologic type cannot be assessed
D2
Non-Hodgkin lymphoma vs Hodgkin lymphoma
PROCEDURE (select all that apply)**
D3
D4
D5
D6
D7
TUMOR SITE (check all that apply)**
D8
C1
C2
Lymph node(s), site unknown
Lymph node(s) - Specify site(s),
D9
C3
Other tissue(s) - Specify site(s):
C4
Not specified
C5
Only one site biopsied, see above
D10
D11
D12
B-cell Lymphoma
B-cell lymphoma, subtype cannot be determined
B-cell lymphoma with high grade features
B-lymphoblastic leukemia/lymphoma, NOS
B lymphoblastic leukemia/lymphoma with recurrent
genetic abnormalities
t(9:22)(q34;q11.2); BCR-ABL1
B lymphoblastic leukemia/lymphoma with t(v;11q23);
MLL rearranged
t(12;21)(p13;q22) TEL-AML 1 (ETV6-RUNX1)
B lymphoblastic leukemia/lymphoma with hyperdiploidy
B lymphoblastic leukemia/lymphoma with hypodiploidy
(hypodiploid ALL)
t(5;14)(q31;q32) IL 3-IGH
---Histologic Types Continued on Next Page----
6.2
Specimen #:
Part:
Patient:
Initials/Date:
HISTOLOGIC TYPE (W HO CLASSIFICATION)** (co
D13
D14
t(1;19)(q23;p13.3); E2A-PBX1
Chronic lymphocytic leukemia/small lymphocytic
lymphoma
D15
D16
D17
D18
D19
D20
Splenic marginal zone lymphoma
Hairy cell leukemia
Hairy cell leukemia-variant
D21
D22
D23
Waldenstrom macroglobulinemia
Heavy chain disease
D24
D25
D26
D27
Plasma cell myeloma
D38
D39
D40
D28
D29
D30
Extraosseous plasmacytoma
mucosa-associated lymphoid tissue (MALT lymphoma)
D41
D42
mucosa-associated lymphoid tissue (MALT lymphoma)
with plasmacytic differentiation
D44
D45
D31
D32
mucosa-associated lymphoid tissue (MALT lymphoma),
pediatric
D33
D34
Nodal marginal zone lymphoma with plasmacytic
differentiation
D35
Nodal marginal zone lymphoma, pediatric
D36
D37
Marginal zone lymphoma, not further specified
Marginal zone lymphoma with plasmacytic
differentiation, not further specified
D43
Follicular Lymphoma
Grade
Follicular lymphoma, grade 1-2
Follicular lymphoma, grade 3A
Follicular lymphoma, grade 3B
Growth Pattern
Follicular lymphoma, growth pattern - follicular
Follicular lymphoma, growth pattern - follicular &
diffuse
Follicular lymphoma, growth pattern - minimally
follicular
Follicular lymphoma, growth pattern not specified
Follicular lymphoma, not further specified
6.2
Specimen #:
Part:
Patient:
Initials/Date:
D63
ALK positive large B-cell lymphoma
D46
D47
Primary cutaneous follicle center lymphoma
Primary cutaneous follicle center lymphoma vs
follicular lymphoma
D64
D65
Large B-cell lymphoma arising in HHV8-associated
D48
Primary cutaneous follicle center lymphoma vs diffuse
large B-cell lymphoma
D49
Primary cutaneous diffuse large B-cell lymphoma, leg
type vs diffuse large B-cell lymphoma, not further
specified
D66
D67
D68
D50
Follicular lymphoma, diffuse follicle center subtype,
grade 1-2
D51
D52
Diffuse large B-cell lymphoma (DLBCL), NOS, germinal
center phenotype
Burkitt lymphoma
D53
Diffuse large B-cell lymphoma (DLBCL), NOS,
non-germinal center phenotype
D54
Diffuse large B-cell lymphoma (DLBCL), NOS, not
further specified
D55
D56
D57
D58
D59
D60
D61
D62
Primary Cutaneous DLBCL, leg type
D69
D70
B-cell Lymphoma - Other (specify):
D71
D72
D73
D74
D75
D76
D77
T-cell Lymphoma
T-cell lymphoma, subtype cannot be determined
T-lymphoblastic leukemia/lymphoma
Chronic LPD of NK-cells
Systemic EBV positive T-cell lymphoproliferative
disease of childhood
D78
D79
6.2
Specimen #:
Part:
Patient:
Initials/Date:
D80
D81
D82
D83
Extranodal NK/T-cell lymphoma, nasal type
D84
D85
D86
D87
D88
D89
D90
D92
Mycosis fungoides
Sézary syndrome
CD30 positive lymphoproliferative disease, NOS
Primary cutaneous CD8-positive aggressive
epidermotropic cytotoxic T-cell lymphoma
Primary cutaneous CD4-positive small/medium T-cell
lymphoma
D93
D94
D95
D96
Anaplastic large cell lymphoma, ALK negative (provisional)
T-cell Lymphoma - Other (specify):
D97
Other
D98
Other (specify):
D91
ANCILLARY STUDIES**
Flow Cytometry-Phenotyping**
E1
separate report
E2
follow
E3
F1
see addendum
performed
F2
F3
G1
G2
report
G3
---ANCILLARY STUDIES Continued on Next Page----
6.2
Specimen #:
Part:
Patient:
Initials/Date:
ANCILLARY STUDIES** (cont'd)
L5
L6
L7
L8
Involvement of multiple lymph node regions on both
sides of diaphragm
Specify sites:
Splenic involvement
Liver involvement
L9
L10
L11
L12
Other organ involvement
Specify:
Not specified
H1
report
H2
H3
J1
J2
J3
J4
report
Genotypic (Molecular) studies pending, report to follow
DNA stored, Genotypic (Molecular) studies not
performed
K1
CLINICAL PROGNOSTIC FACTORS AND INDICES
(Select all that apply)
M1
M2
International Prognostic Index (IPI) (specify):
Follicular Lymphoma International Prognostic Index
M3
(FLIPI) (specify):
B symptoms present
M4
Other (specify):
Specify:
EXTENT OF PATHOLOGICALLY EXAMINED TUMO
L1
L2
L3
Involvement of a single lymph node region
Specify site:
Involvement of multiple lymph node regions on same
side of diaphragm
L4
Specify sites:
Comment:
6.2
Hodgkin Lymphoma Biopsy/Staging Synoptic Template
Specimen #:
Part:
Patient:
Initials/Date:
- - - - - - - - - - - - - - MACROSCOPIC - - - - - - - - - - - - - - A1
A2
A3
A4
A5
TUMOR SIZE (largest single mass) - Resections Only
SPECIMEN TYPE**
D1
Greatest dimensions:
Lymphadenectomy (specify sites):
Staging laparotomy
D2
D3
D4
Additional dimensions:
Specify site:
Cannot be determined (see Comment)
Extranodal
Other
(specify):
(specify):
Not specified
cm.
cm.
- - - - - - - - - - - - - - MICROSCOPIC - - - - - - - - - - - - - - - -
HISTOLOGIC SUBTYPE**
PROCEDURE**
B1
B2
B3
Fine needle aspiration
Needle core biopsy
Biopsy, other
E1
B4
B5
B6
Resection
Other (specify):
Unknown
E2
E3
E4
Nodular lymphocyte predominant Hodgkin lymphoma
(NLPHL)
Nodular sclerosis classical Hodgkin lymphoma (NSHL)
Mixed cellularity classical Hodgkin lymphoma (MCHL)
Lymphocyte-rich classical Hodgkin lymphoma (LRCHL)
TUMOR SITE (check all that apply)**
E5
E6
Lymphocyte-depleted classical Hodgkin lymphoma (LDHL)
Classical Hodgkin lymphoma, further subtype cannot be
E7
Hodgkin lymphoma, subtype cannot be determined
E8
Other (specify):
F1
F2
F3
Not applicable
Grade I
Grade ll
F4
Grade uncertain
C1
Lymph node(s), site not specified
C2
Lymph node(s) - specify sites(s):
C3
C4
C5
Other tissue(s) or organ(s) - specify
site(s):
Not specified
Only one site biopsied, see above
determined
HISTOLOGIC GRADE (NSHL only) - OPTIONAL
Specimen #:
Part:
Patient:
Initials/Date:
EXTENT OF PATHOLOGICALLY EXAMINED TUMO
G1
Involvement of a single lymph node region.
G2
Specify site:
Involvement of multiple lymph node regions on the
same side of the diaphragm.
G3
J1
J2
see addendum
performed
J3
Specify sites:
Involvement of multiple lymph node regions on both
sides of the diaphragm.
Specify sites:
Splenic involvement
K1
G4
G5
G6
G7
G8
G9
Liver involvement
Other organ involvement
Specify:
Not specified
K2
report
K3
ANCILLARY STUDIES**
L2
report
L3
M1
report
M2
Genotypic (Molecular) studiending, report to follow
M3
M4
DNA stored,Genotypic (Molecular) studies not performed
L1
Flow Cytometry - Phenotyping**
H1
H2
H3
separate report
follow
Specimen #:
Part:
Patient:
Initials/Date:
N1
N2
N3
Progressive transformation of germinal centers (PTGC)
Castleman disease
Other (specify): ________________________________
CLINICAL PROGNOSTIC FACTORS AND INDICES
P1
P2
International Prognostic Score (IPS) (specify):
B symptoms present
P3
Other (specify): ____________
Comment:
Web-Based Resources
WEBSITE EDUCATIONAL RESOURCES & CALL SCHEDULES
Division of Hematopathology Intranet website (Hematopathology schedules/paging and general
information)
1.
http://path.upmc.edu/divisions/hematopath.html
UPMC Pathology Residents Server (includes on call schedule for AP and CP)
1. https://pathologyresidents.shp.upmc.com/SitePages/Home.aspx
Hematological Malignancies Program
1.
http://www.upmccancercenter.com/portal_hema/overview.cfm
For general pathology (Hematopathology, Dermatopathology and others)
1. http://www-medlib.med.utah.edu/WebPath/webpath.html
2. http://dermatlas.med.jhmi.edu/derm (Users can search by categories, diagnoses, or body site)
3. www.uscap.org (numerous teaching resources)
4. http://www.pathologyoutlines.com
HEMATOPATHOLOGY
Atlas
1. http://www.ashimagebank.org/
2. http://www.bloodmed.com/home/
Virtual Slide Set
1. https://epssecure.upmc.com/hematopathology/index.cfm (or link via residents web page
http://pathologyresidents.shp.upmc.com/SitePages/Home.aspx -- the link to Hematopathology virtual
slide set is on the right hand side (direct link to virtual slide set Division of Hematopathology UPMC
Presbyterian)
2. http://cclcm.ccf.org/vm/VM_cases/lymphoid_main.htm
(Virtual Hematopathology slides (and other fixed images) from Cleveland Clinic)
3. www.uscap.org (Virtual Slide Box at USCAP)
General
1. http://www.sh-eahp.org/
2. http://medmark.org/hem/
3. http://www.cancer.gov/ (treatment of leukemias/lymphoma)
Case Studies
1. http://path.upmc.edu/cases.html
2. http://teachingcases.hematology.org/
USCAP Hematopathology Evening Session Cases
1.
http://www.uscap.org/
Societies
1. http://www.hematology.org/
2. http://www.aspho.org/
3. http://www.blacksci.co.uk/uk/society/bsh/default.htm
4. http://www.leukemia.org/
Educational Site
1. http://www.cyto.purdue.edu/index.htm
2. http://flowcyt.cyto.purdue.edu/flowcyt/educate/pptslide.htm
3. http://enjoypath.com/
Cases and Tests
1. http://www.madsci.org/~lynn/VH/APIII/CPflow.html
Societies
1. http://www.cytometry.org/
2. http://www.isac-net.org/
Books
1.
http://www.cyto.purdue.edu/cdroms/cyto2/14/pucl/flowcyt/refclin.htm
CYTOGENETICS
1. http://www.pathology.washington.edu/galleries/Cytogallery/main.php
Flow Cytometry
1. http://www.bloodjournal.org/content/bloodjournal/111/8/3941.full.pdf
NOTE: IF THERE ARE ANY SITES YOU FEEL SHOULD BE ADDED TO THIS LIST OR DEFUNCT SITES,
PLEASE LET DR. SWERDLOW OR DR. GIBSON KNOW
Online Conference Access for Pathology Faculty and Residents


Visit Department of Pathology Conference Access for Pathology Faculty and Residents
http:/pathologyconference.upmc.edu
Weekly Conference includes:
 Anatomic Pathology Grand Rounds conference
 Departmental Seminar (Archived)
These LIVE and archived conferences are only accessible through the UPMC network.
Note: Additional non-web based resources are in UPMCPresbyterian G304, G315 and G323.

Hematopathology Resident / Fellow Manual

Transcription

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