Development and prognostic relevance of a histologic grading and staging system for alcohol-related liver disease.

BACKGROUND & AIMS: The SALVE Histopathology Group (SHG) developed and validated a grading and staging system for the clinical and full histological spectrum of alcohol-related liver disease (ALD) and evaluated its prognostic utility in a multinational cohort of 445 patients. METHODS: SALVE grade was described by semiquantitative scores for steatosis, activity (hepatocellular injury and lobular neutrophils) and cholestasis. The histological diagnosis of steatohepatitis due to ALD (histological ASH, hASH) was based on the presence of hepatocellular ballooning and lobular neutrophils. Fibrosis staging was adapted from the Clinical Research Network staging system for non-alcoholic fatty liver disease and the Laennec staging system and reflects the pattern and extent of ALD fibrosis. There are 7 SALVE fibrosis stages (SFS) ranging from no fibrosis to severe cirrhosis. RESULTS: Interobserver κ-value for each grading and staging parameter was >0.6. In the whole study cohort, long-term outcome was associated with activity grade and cholestasis, as well as cirrhosis with very broad septa (severe cirrhosis) (p <0.001 for all parameters). In decompensated ALD, adverse short-term outcome was associated with activity grade, hASH and cholestasis (p = 0.038, 0.012 and 0.001, respectively), whereas in compensated ALD, hASH and severe fibrosis/cirrhosis were associated with decompensation-free survival (p = 0.011 and 0.001, respectively). On multivariable analysis, severe cirrhosis emerged as an independent histological predictor of long-term survival in the whole study cohort. Severe cirrhosis and hASH were identified as independent predictors of short-term survival in decompensated ALD, and also as independent predictors of decompensation-free survival in compensated ALD. CONCLUSION: The SALVE grading and staging system is a reproducible and prognostically relevant method for the histological assessment of disease activity and fibrosis in ALD. LAY SUMMARY: Patients with alcohol-related liver disease (ALD) may undergo liver biopsy to assess disease severity. We developed a system to classify ALD under the microscope by grading ALD activity and staging the extent of liver scarring. We validated the prognostic performance of this system in 445 patients from 4 European centers.

Terminologia Histologica 10 years on: some disputable terms in need of discussion and recent developments.

At first sight, the issue of morphological terminology may seem to be a "closed and unchanging chapter", as many of the structures within the human body have been known for decades or even centuries. However, the exact opposite is true. The initial knowledge of the microscopic structure of the human body has been continuously broadening thanks to the development of new specialized staining techniques, discovery of the electron microscope, or later application of histochemical and immunohistochemical methods into routine tissue examination. Contrary to popular belief, histology has a status of constantly developing scientific discipline, with continuous influx of new knowledge, resulting in an unavoidable necessity to revise the histological nomenclature at regular intervals. The team of experts of the Federative International Programme on Anatomical Terminology, a working group of the International Federation of Associations of Anatomists, published in 2008 the First Edition of Terminologia Histologica. Terminologia Histologica (TH) is the best and most extensive of all the histological nomenclatures ever issued. However, here we suggest that several terms of important histological structures are still missing while several other terms are disputable. First, we present some clinically important terms of cells and tissue structures for inclusion in the next TH and, in a second part, we refer to some new terms in the current edition of the TH which are not yet mentioned in current histology textbooks (e.g., fusocellular connective tissue, bundle bone as the third type of bone tissue, spongy layer of vagina or arteria vaginata from the splenic white pulp). With this article we hope to start a wide scientific discussion which will lead to an inambiguous definition and demonstration of typical examples of all terms in the TH, with the result that the new edition of the Terminologia Histologica will become an internationally accepted communication tool for all practitioners and teachers of histology alike.

Comparing the accuracy of PCR-capillary electrophoresis and cuticle microhistological analysis for assessing diet composition in ungulates: A case study with Pyrenean chamois.

The study of diet composition is required to understand the interactions between animal and plant ecosystems. Different non-invasive techniques applied on faecal samples have commonly been used for such purposes, with cuticle microhistological analysis (CMA) and emerging DNA-based methods being the most relevant. In this work, we refined and optimized a qualitative DNA-based approach combining PCR amplification of long trnL(UAA) and ITS2 fragments and capillary electrophoresis (PCR-CE), instead of short trnL(UAA) fragments and massive sequencing technologies commonly reported. To do so, we developed a controlled diet assay using a stabled Pyrenean chamois specimen (Rupicapra pyrenaica pyrenaica), which included representative herbaceous and shrubby plant species. We also assessed the impact of sample freshness on the diet determination of this mountain caprinae by exposing faecal samples to the outdoor environment for three weeks. Faecal samples from both experiments were analysed by qualitative PCR-CE and semi-quantitative CMA in order to compare the pros and cons of both approaches. Our results show that all of the offered plant species were detected by both methodologies although CMA over-detected shrubs compared to herbaceous species. At the same time, sample degradation due to sustained climate exposure is a limiting factor for molecular analysis, but not for CMA. Taken all together, our results suggest that the qualitative information obtained by CMA and PCR-CE can be interchangeable when faecal samples are fresh (less than one week after deposition) but, afterwards, molecular analysis underestimates diet composition probably due to DNA degradation. CMA, however, can accurately be used at least three weeks after defecation. Moreover, by combining the results of simultaneous PCR amplification of two complementary genes, this optimized PCR-CE methodology provides a reliable, feasible and more affordable alternative for multiple and routine analyses of complex samples. Neither CMA nor PCR-CE seems to solve comprehensively the quatification of herbivore diets and thus further research needs to be done.

Obtaining tissue diagnosis in lung cancer patients with poor performance status and its influence on treatment and survival.

INTRODUCTION: 25% of patients with lung cancer have performance status 3 or 4. A pragmatic approach to investigative procedures is often adopted based on the risks and benefits in these patients and whether tissue diagnosis is necessary for anticipated future treatment. This cohort study investigated factors influencing a clinician's decision to pursue a tissue diagnosis in patients with lung cancer and performance status 3 and 4 and to examine the association of tissue diagnosis with subsequent management and survival. METHODS: All patients with lung cancer diagnosed in North Glasgow from 2009 to 2012 were prospectively recorded in a registry. We investigated the relationships between achieving a tissue diagnosis, treatment and survival. RESULTS: Of 2493 patients diagnosed with lung cancer, 490 patients (20%) were PS 3 and 122 patients (5%) were PS 4. Tissue diagnosis was attempted in 60% and 35% patients with PS 3 and PS 4 respectively. Younger age, better performance status and having stage 4 disease were independently associated with a diagnostic procedure being performed. Only 5% of patients with poor performance status received treatment conventionally requiring a tissue diagnosis. Age, stage and performance status were independent predictors of mortality. Achieving a tissue diagnosis was not associated with mortality. Receiving treatment requiring tissue diagnosis is associated with survival benefit. CONCLUSIONS: The majority of patients with poor fitness undergo a diagnostic procedure which does not influence further treatment or affect survival. However, the cohort of patients who do undergo therapy determined by tissue diagnosis have improved survival.

A novel quantitative approach for eliminating sample-to-sample variation using a hue saturation value analysis program.

OBJECTIVES: As computing technology and image analysis techniques have advanced, the practice of histology has grown from a purely qualitative method to one that is highly quantified. Current image analysis software is imprecise and prone to wide variation due to common artifacts and histological limitations. In order to minimize the impact of these artifacts, a more robust method for quantitative image analysis is required. METHODS AND RESULTS: Here we present a novel image analysis software, based on the hue saturation value color space, to be applied to a wide variety of histological stains and tissue types. By using hue, saturation, and value variables instead of the more common red, green, and blue variables, our software offers some distinct advantages over other commercially available programs. We tested the program by analyzing several common histological stains, performed on tissue sections that ranged from 4 µm to 10 µm in thickness, using both a red green blue color space and a hue saturation value color space. CONCLUSION: We demonstrated that our new software is a simple method for quantitative analysis of histological sections, which is highly robust to variations in section thickness, sectioning artifacts, and stain quality, eliminating sample-to-sample variation.

Regulatory forum opinion piece: blind reading of histopathology slides in general toxicology studies.

With the intention of reducing bias, a recent European Food Safety Authority draft guidance document included a recommendation for blinded evaluation of histopathology slides in general toxicology studies (EFSA 2011). Although blinding as to treatment status reduces bias in many types of scientific experiment and is sometimes also appropriate in toxicologic pathology (Holland and Holland 2011), it is most unlikely to help achieve the overall goal of improved human safety when used for routine histopathology evaluation of tissues in general toxicology studies. This is the case because (1) blinding is not applicable to the inductive reasoning process used to identify test article effects in the tissues and would dramatically reduce the chances of these being successfully identified; and (2) in any case, the bias that would be reduced by blinding is actually a bias favoring diagnosis of a toxicological hazard and a conservative safety evaluation, which is appropriate in this context. Other unintended consequences of blinding histopathology evaluation include reductions in sensitivity for a variety of additional reasons and increased subjectivity of the pathology data.

An analysis of predictive biomarkers in routine histopathological reporting of infiltrating ductal breast carcinoma in a tertiary hospital in Malaysia with a focus on limitations and directions for future development.

Predictive biomarkers such as oestrogen (ER) and progesterone (PR) receptors and c-erbB-2 oncoprotein have become a staple in breast cancer reports in the country as they increasingly play an important role in the treatment and prognosis of women with breast cancers. This study reviews the practice of histopathology reporting of these biomarkers in a Malaysian tertiary hospital setting. Retrospective data on demographic, pathological and biomarker profiles of patients with invasive ductal carcinoma who had undergone mastectomy or lumpectomy with axillary node clearance from 2005 to 2006 were retrieved from the Department of Pathology, Penang Hospital and analysed. The prevalence of ER positivity (55.8%), PR positivity (52.5%), c-erbB-2 oncoprotein overexpression (24%) and triple negativity (ER negative, PR negative, c-erbB-2 negative) (15%) by immunohistochemistry were comparable with other studies. Notably, c-erbB-2 overexpression was equivocal (2+) in 15% of cases. Since about a quarter of equivocal (2+) cases usually show amplification by FISH, a small but certain percentage of patients would miss the benefit of anti-c-erbB-2 antibody therapy if FISH is not performed. New ASCO/CAP guidelines on the quantitation of ER and PR will probably increase the prevalence of ER/PR positivity, invariably leading to significant ramifications on the management of patients as more patients would be deemed eligible for endocrine therapy, as well as categorisation of triple negative breast cancers.

Reporting of toxicologic histopathology: contrasting approaches in diagnostic versus experimental practice.

There are substantial differences between the information required in a diagnostic histopathology report and an experimental pathology report. A diagnostic report rests on the authority of the person issuing it, so there is less emphasis on the data and analysis on which the diagnosis is based being in the report. By contrast, an experimental report gains its authority from the integrity of the data and the objective analysis of that data. It is recommended that the current diagnostic reporting of the histopathology component of toxicological studies be changed to a more experimental report approach.

Fabrication and characterization of solid lipid microparticles of ketoprofen

Solid lipid microparticles (SLMs) loaded with ketoprofen were prepared by single emulsion-solvent evaporation method, in which glyceryl monostearate and Tween 80 were employed. The particle size was found to be 99.80±2.1μm. Microparticles observed by scanning electron microscope (SEM) showed spherical shape. The entrapment efficiency (EE %) and drug loading capacity (DL %) were found to be 72.60±1.6 % and 17.98±0.7% respectively. Results of stability evaluation showed relatively long term stability after storage at 4˚C for 3 months. The in-vivo study revealed slightly better per cent inhibition of pain i.e. 74% in comparison with 68% produced by plain drug(AU)

Las micropartículas lipídicas sólidas (MLS) cargadas con ketoprofeno se han preparado a través del método de evaporación del disolvente en emulsión simple, en el que se ha utilizado monoestearato de glicerilo y Tween 80. El tamaño de la partícula ha resultado ser de 99,80±2,1 μm. Las micropartículas observadas a través del microscopio electrónico de barrido (MEB) han mostrado una forma esférica. La eficacia de compresión (EC %) y la capacidad de concentración (CC %) del fármaco han resultado ser de 72,60±1,6% y 17,98±0,7% respectivamente. Los resultados de la evaluación de estabilidad han mostrado una estabilidad relativa a largo plazo después de una conservación a 4˚C durante 3 meses. El estudio in vivo ha revelado un ligero mejor porcentaje de inhibición del dolor, es decir, un 74% en comparación con un 68% producido por un fármaco corriente(AU)

Best practices for evaluation of bone marrow in nonclinical toxicity studies.

This manuscript is intended to provide a best practice approach to accurately and consistently assess toxicant-induced bone marrow effects of test articles. In nonclinical toxicity studies, complete blood count data in conjunction with the histological examination of the bone marrow are recommended as the foundation for assessing the effect of test articles on the hematopoietic system. This approach alone can be used successfully in many studies. However, in some situations it may be necessary to further characterize effects on the different hematopoietic lineages, either by cytological or flow cytometric evaluation of the bone marrow. Both modalities can be used successfully, and which one is selected will depend on the expertise, preference of the facility, and the nature of the change in the bone marrow. Other specialized techniques such as clonogenic assays or electron microscopy are used rarely to further characterize hematotoxicity. The indications and techniques to successfully employ histological, cytological, or flow cytometric evaluation as well as clonogenic assays and electron microscopy are reviewed.

Using LEAN principles to improve quality, patient safety, and workflow in histology and anatomic pathology.

Histology and anatomic pathology have historically been slow to accept many of the process changes that have been widely accepted in the clinical laboratory. In this article, we describe the application of the Toyota Production System (LEAN) to histology and anatomic pathology as implemented at the Avera McKennan Hospital laboratory. Avera McKennan is the flagship hospital of the Avera Health System, a faith based, not for profit healthcare system based in South Dakota. Comprised of 235 hospitals, clinics, and physicians, with over 12,000 employees, Avera Health is one of the largest healthcare systems in the region. Beginning in 2004, Avera McKennan's laboratory began its "LEAN journey" and in the intervening years has expanded it throughout all areas of the laboratory. Following the example set by the laboratory, many other areas of the hospital have joined in the LEAN Process Improvement journey. In January 2009, the Avera McKennan Laboratory became the first hospital laboratory in the US to achieve the CAP ISO-15189 accreditation in both clinical and anatomic pathology.

Histology: a unique area of the medical laboratory.

Fundamental differences in samples, procedures, nature of results, automation, productivity, staffing levels, and background decision making along work flow and turnaround times characterize histology as a unique area within the medical laboratory. For histology laboratories to function successfully, individual and collective training, well-defined goals, and implemented accountabilities with effective supervision are required. The pathologist, as immediate client of the histology laboratory, has to be involved in the whole operation to assure optimal patient care.

The use of histology in 638 coronial post-mortem examinations of adults: an audit.

An audit was performed to determine the effectiveness of histological sampling of forensic post-mortem cases based on a review of three years' data, which comprised 638 adult autopsy cases. During the study period organs and tissues that appeared macroscopically normal and abnormal were extensively sampled. Histology was regarded as in some way contributory (providing, altering or confirming a cause of death) 53% of the time. The use of histology provided the cause of death in 49 (24%) of the 203 cases not given a cause of death after the completion of the macroscopic examination. When an interim cause of death had been supplied following the completion of the gross examination it was changed in 4.8% of cases, but there were no changes of the manner of death. The majority of the histological diagnoses or discrepancies involved the lungs and the heart. All diagnoses relevant to determining the cause of death would have been made if samples had been taken only from the left ventricle, right ventricle, coronary arteries, lungs, kidneys and brain with any tissue or organ that appeared abnormal macroscopically. A macroscopically identified abnormality that appeared to have been responsible for death was not sampled in 20 cases; consequently, more attention will be paid to sampling macroscopically abnormal tissues. As a result of this audit histology sampling practice has been revised and will be re-audited in the future.

Are external quality assurance (EQA) slide schemes a valid tool for the performance assessment of histopathologists?

Quality assurance plays a vital role in the healthcare profession and histopathologists play a central role in the diagnosis and treatment of disease. In the past these specialists have worked in isolation and quality assurance of their work has been difficult. In recent years this has changed with the introduction of External Quality Assurance slide schemes. This paper discusses how these schemes have evolved, the problems of standard setting and their validity as a measure of pathologists performance.

[How important is the clinical context for a histopathological diagnosis?]. / Diagnostic anatomopathologique: l'importance du contexte clinique.

A histopathological examination consists of two distinct phases: observation and interpretation. As a rule, macro- and microscopical examination give strong diagnostic indicators and the diagnosis is made instantaneously: the two phases are strongly interwoven. Also, the clinical context often provides essential clues as to the final diagnosis. A request for a pathology examination must hence come with clinical informations and a specific question. Yet, the pathologist has to keep in mind that the interpretation of what he sees might follow too enthusiastically the proposed clinical diagnosis. It is hence preferable for the pathologist to take note of the clinical context only after the microscopic examination has been accomplished.