Cellular Pathology - University Hospitals Birmingham

Due to the wide range of cellular pathology specimens several key container types exist as below.  The size of the specimen container must be appropriate to the size of the specimen.

To ensure that cases are not delayed within the laboratories please make sure that the request form is correctly completed and all sections are filled in properly. Once received urgent cases will be highlighted by the specimen reception and prioritised appropriately in the departmental workload. 

Please note many of the technical preparation aspects of cytology may take place at the Heartlands Hospital Cell Path Laboratory.

Intra-operative Frozen Sections

The department provides a rapid diagnostic service for intra-operative tissue specimens. Requests for frozen section should be telephoned to the histopathology laboratory (at QE site 0121 371 13314 and at BHH site 0121 424 3188 ) in advance of the procedure being undertaken, preferably on the day prior to surgery. Where this is not possible, e.g. an incidental finding during surgery, the request should still be telephoned to the laboratory prior to the sample leaving theatre. When calling the laboratory please ensure that you have the following information available as it will be asked for by the person receiving the call: 

Tissue taken for frozen section should be placed into a suitably sized container without any form of fixative (i.e. dry) and sent in a secondary bag/container to Cellular Pathology without delay.  The transport of the fresh material is arranged by the requesting clinical team, typically using a UHB Hospital porter.  Theatre books should be used to record the audit trail from theatre and safe receipt in the laboratory.  The process from specimen receipt in the laboratory to verbal report issued takes 15 to 30  minutes however this time may be shortened or lengthened slightly based on the nature of the sample received.  High risk biohazardous tissues are not suitable for frozen sectioning unless absolutely clinically required. Examples of these include tuberculous lesions, specimens from patients with viral hepatitis and specimens from patients who are HIV positive. If there is any doubt as to whether the specimen is suitable or not please contact the laboratory and ask for the advice of a Consultant Pathologist.

Immunofluorescence

Direct immunofluorescence is used for the detection of tissue bound proteins such as antibodies and complement. Two types of tissue, skin or renal, are processed, although occasionally others may be submitted (e.g. oral mucosa, conjunctiva). Biopsies are taken from patients; snap-frozen and sectioned prior to incubation with fluorescein isothiocyanate (FITC) conjugated anti-sera. This method allows for the detection of tissue bound antibodies when there may be insufficient levels to detect in serum. Other tissue reactants such as complement and fibrinogen can also be detected. In some disease states patterns of staining can be diagnostic.

MOHS

Mohs, is microscopically controlled surgery used to treat common types of skin cancer. During the surgery, after each removal of tissue and while the patient waits, the fresh tissue is snap frozen and sectioned for microscopic examination. The examination informs the decision for additional tissue removal.

The process from specimen receipt in the laboratory to verbal report issued takes no longer than 15 minutes per sample block however complex specimens with multiple samples will take additional time.

Mohs clinics are booked with the Department to ensure that there are clinical and technical staff are available to complete the test.  Mohs surgery is carried out at Solihull and QE Hospital sites.

Neuropathological Smears

The Department provides a rapid diagnostic service for intra-operative brain tissue specimens. Requests for neuro smears should be telephoned to the laboratory in advance as per intra-operative frozen sections.

Tissue taken for neuropathological smears should be placed into a sterile universal container (UC) without any form of fixative (i.e. dry) and sent to Cellular Pathology without delay. These specimens are often tiny and so any delay in receipt may lead to artefactual damage which can be detrimental to any further laboratory processing.

The process from specimen receipt in the laboratory to verbal report issued takes  15 - 30  minutes however this time may be shortened or lengthened slightly based on the nature of the sample received.

Small Biopsy Specimens

The Department provides both a routine and urgent diagnostic service for small biopsy specimens.

Specimens should be placed into 60 mL pre-filled containers of neutral buffered formalin.

• Wherever possible small or endoscopic biopsies should be placed into mini biopsy or microcassettes cassettes (small yellow cassettes) before being placed into the neutral buffered formalin pots. Supplies of cellsafe cassettes can be sourced from the Cellular Pathology Specimen Reception.

• Breast or other fine cores may be placed onto white cards before being placed into neutral buffered formalin pots. Please ensure the cores are stretched out linearly prior to fixation as knotted cores are not easy to separate out in the laboratory.

Please note that biopsies are delicate and should be handled with care, avoid the use of forceps wherever possible to prevent trauma artefact to the tissue.

Urgent Biopsy Specimens (Rapid Paraffin Service)

The Department provides a rapid paraffin service for clinically urgent biopsy specimens; a report can be issued on the same day that the specimen arrives in the department.  It should be noted however that not all specimens are suitable for rapid processing. In general terms only liver, renal and cardiac biopsies are processed in this way. Other specimens may be suitable however advice should be sought from the Histopathology Manager (0121 371 3352) or a trimming room senior Biomedical Scientist (0121 371 3314) prior to sending other tissue types.

Tissues for the rapid paraffin service must be received by the department no later than 13:30. Please ensure that the name and bleep number of the requesting clinician is clearly indicated on the request form to allow for the verbal report to be issued.

Specimens received after 13:30 will not be processed urgently and will be placed onto the “normal” biopsy run later in the day thus same day reporting will not be possible.

Resection Specimens

The department provides a routine and urgent diagnostic histopathology service for larger surgical resection specimens. Tissue should be placed into appropriately sized containers which will allow for the specimen and at least ten times its volume in fixative (i.e. neutral buffered formalin) to be contained.

DO NOT use containers which are too small to allow for this volume of fixative to be used or squash specimens into small pots. Specimens should be free-floating in fixative not pressed up against the sides of the container as this leads to distortion of the tissue and may make further processing unnecessarily difficult.

Reporting

Once specimens are reported and authorised by the laboratory they can be accessed on the intranet by appropriate staff. In addition a typed copy will be sent to the destination specified on the request form (FOR EXTERNAL USERS ONLY). If the specimen is needed for a particular MDT or clinic, then please state this on the request form. Urgent reports can be issued verbally if necessary to a suitable member of medical staff. Please put a mobile telephone number or a bleep number (that will be answered immediately) on the request form. Telephone reports will only be issued on request via telephone.

Laboratory Turnaround Times

The Department monitors turnaround times on a regular basis and reviews significant delays or service issues within the Trust's Divisional Diagnostic Performance monthly meetings.  7, 10 and 14 day Cellular Pathology turnaround target reporting times are reported to Trust service users, broken down by clinical specialty for biopsies and for cancer tracking cases for each month.  Specific turnaround data is available to service users upon request in addition to UHB internally available histopathology intranet dashboards.  The agreed routine TATs for each specialty is 14 days to first reported for greater than or equal to 90% of cases, within tolerance = 75% - 90% reported in 14 days.  Targets for reporting are not consistantly met, but of note is some more complex haematopathology and urology cases  may require additional work e.g.  immunohistochemistry or molecular pathology and this does add to reporting times for complex cases.  

In addition the Department actively monitors outstanding cases, notifying reporting pathologists that cases are still unreported.  This and actions to increase lab and consultant capacity continue to support the delivery of improved TATs for service users.

Muscle Biopsy Service :

• Histochemistry results is 7 days
• The current turnaround time for cases referred to specialist centres is 2-3 months depending on tests requested.

Electron Microscopy :

• Renal and cardiac turnaround times are approx. 10 to 14 days, TATs may be longer with a small specialist EM team
• Muscle and nerve biopsies approx. 10 to 14 weeks.

Referral Laboratories and second opionons

For some complex cases outside, second opinions may be requested  internally within UHB but also externally to support the diagnostic report and this may add to the number of days before a final diagnostic report is issued.   List of key contacts we currently use for specialist second opinions and referral labs used for testing is available upon request. 

 Unaccredited testing

The Department regularly reviews testing to reflect clinical service needs and advances in technology.  Consequently, some testing and equipment has not yet been reviewed at UKAS assessment visit.  The following testing and aspects of Cellular Pathology are not covered by UKAS 15189 accreditation:

Sputum Analysis - Differential cell count performed on induced and non-induced sputum samples. A developmental diagnostic tool to deliver accurate severe asthma diagnosis and phenotyping.  This will be a step towards patient tailored medicine delivery in severe asthma and will enhance our Trust position as a leading national centre in the management of severe asthma.

Digital Pathology - the Department is performing extensive clinical validation towards going live with digital pathology during 2024.  3D HISTECH - PANNORAMIC 480, Hamamtsu S60 and S360 slide scanners are used as part of a Sectra IDS7 software solution for viewing and reporting digital images.  This will be subject to a UKAS 'Extention to accredited scope' application later in 2025. To enable this PACS reporting went live during 2024.