Development of immunohistochemistry services for cancer care in western Kenya: Implications for low- and middle-income countries.

BACKGROUND: Cancer is becoming a major cause of mortality in low- and middle-income countries. Unlike infectious disease, malignancy and other chronic conditions require significant supportive infrastructure for diagnostics, staging and treatment. In addition to morphologic diagnosis, diagnostic pathways in oncology frequently require immunohistochemistry (IHC) for confirmation. We present the experience of a tertiary-care hospital serving rural western Kenya, which developed and validated an IHC laboratory in support of a growing cancer care service. OBJECTIVES METHODS AND OUTCOMES: Over the past decade, in an academic North-South collaboration, cancer services were developed for the catchment area of Moi Teaching and Referral Hospital in western Kenya. A major hurdle to treatment of cancer in a resource-limited setting has been the lack of adequate diagnostic services. Building upon the foundations of a histology laboratory, strategic investment and training were used to develop IHC services. Key elements of success in this endeavour included: translation of resource-rich practices to a resource-limited setting, such as using manual, small-batch IHC instead of disposable- and maintenance-intensive automated machinery, engagement of outside expertise to develop reagent-efficient protocols and supporting all levels of staff to meet the requirements of an external quality assurance programme. CONCLUSION: Development of low- and middle-income country models of services, such as the IHC laboratory presented in this paper, is critical for the infrastructure in resource-limited settings to address the growing cancer burden. We provide a low-cost model that effectively develops these necessary services in a challenging laboratory environment.

Development of imunohistochemistry services for cancer care in western Kenya: implications for low-and middle-income countries

Background: Cancer is becoming a major cause of mortality in low- and middle-income countries. Unlike infectious disease; malignancy and other chronic conditions require significant supportive infrastructure for diagnostics; staging and treatment. In addition to morphologic diagnosis; diagnostic pathways in oncology frequently require immunohistochemistry (IHC) for confirmation. We present the experience of a tertiary-care hospital serving rural western Kenya; which developed and validated an IHC laboratory in support of a growing cancer care service. Objectives; methods and outcomes: Over the past decade; in an academic North-South collaboration; cancer services were developed for the catchment area of Moi Teaching and Referral Hospital in western Kenya. A major hurdle to treatment of cancer in a resource-limited setting has been the lack of adequate diagnostic services. Building upon the foundations of a histology laboratory; strategic investment and training were used to develop IHC services. Key elements of success in this endeavour included: translation of resource-rich practices to are source-limited setting; such as using manual; small-batch IHC instead of disposable- and maintenance-intensive automated machinery; engagement of outside expertise to develop reagent-efficient protocols and supporting all levels of staff to meet the requirements of an external quality assurance programme. Conclusion: Development of low- and middle-income country models of services; such as the IHC laboratory presented in this paper; is critical for the infrastructure in resource-limited settings to address the growing cancer burden. We provide a low-cost model that effectively develops these necessary services in a challenging laboratory environment

Myocardial abscess and fatal cardiac arrhythmia in a hemodialysis patient with an arterio-venous fistula infection.

Myocardial abscess formation is a life-threatening complication that is frequently but not exclusively associated with infective endocarditis. To our knowledge there are only two case reports of myocardial abscess formation in hemodialysis patients. Only one of these reports describes a myocardial abscess of bacterial etiology secondary to an infected intravascular hemodialysis catheter. Furthermore, there are no reports of bacterial myocardial abscess occurring in a hemodialysis patient with an infected arteriovenous fistula. Myocardial abscess can manifest in a variety of clinical scenarios ranging from an asymptomatic state to a catastrophic myocardial wall rupture. In the case described, the myocardial abscess lead to a rapidly progressive course consisting of recurrent cardiac arrhythmias that were ultimately fatal. Our case involved the formation of a myocardial abscess in the presence of a methicillin-resistant Staphylococcus aureus bacteremia without any evidence of infective endocarditis. We report this case to call attention to the possibility of bacterial myocardial abscess occurring with infection of an arteriovenous fistula in a hemodialysis patient, which can manifest as recurrent severe cardiac arrhythmias refractory to medical therapy.

Molecular evidence for the same clonal origin of multifocal papillary thyroid carcinomas.

PURPOSE: Patients with papillary thyroid carcinoma often have two or more distinct papillary tumors at thyroidectomy. Whether these multifocal papillary lesions are clonally related or whether they arise independently is unknown as previous studies have shown conflicting results. Molecular analysis of microsatellite alterations and X-chromosome inactivation status in separate tumors from the same patient can be used to define the genetic relationships among the multiple coexisting tumors. EXPERIMENTAL DESIGN: We examined 64 separate tumors from 22 female patients who underwent thyroidectomy for thyroid carcinoma. All patients had multiple and separate papillary carcinomas (range, two to six). Genomic DNA samples were prepared from formalin-fixed, paraffin-embedded tissue sections using laser-capture microdissection. Loss of heterozygosity assays for three microsatellite polymorphic markers for putative tumor suppressor genes on chromosomes 3p25 (D3S1597), 9p21 (D9S161), and 18p11.22-p11 (D18S53) were done. In addition, X-chromosome inactivation analysis was done on the tumors from all patients. RESULTS: Twenty of 22 (91%) cases showed allelic loss in one or more of the papillary lesions in at least one of the three polymorphic markers analyzed. Concordant allelic loss patterns between coexisting papillary tumors were seen in 20 of 23 (87%) cases. A concordant pattern of nonrandom X-chromosome inactivation in the multiple coexisting papillary lesions was seen in all informative cases. CONCLUSION: Our data suggest that the multifocal tumors in patients with papillary thyroid carcinoma often arise from the same clone. Thus, intrathryoid metastasis may play an important role in the spread of papillary thyroid carcinoma, a finding that has important therapeutic, diagnostic, and prognostic implications.