[Histonet] RE: negative IHC controls

[Hadi Yaziji]

Thanks for sharing your CV with us.

You seem to be fixated on how slides should be filed. It's quite easy 
in our laboratory (and any other laboratory) to find the positive QC's, 
because they're filed chronologically (is there any other way to file 
slides?). First you find out the date the case in question was run, and 
you go to the QC file cabinet and pull the positive QC's that belong to 
the same day. Negative QC's (and again, one slide per tissue block) are 
filed with the case.

As to your "evidence based good practice", please don't generalize. Two 
hospitals across the street from each other can represent two extremes 
of quality of care. Actually, I happened to have spent a month in a 
prestigious Histopathology Department in London nine years ago. The 
quality of IHC in their lab was superb, but it was miserable in the 
hospital right across the street from them. The same applies to the US 
and any other country.

Finally, if my last email was unprofessional and insulting to you, 
please accept my apology. Please remember that it was your unnecessary 
use of the terms "dam fool"  and "poor quality control by any 
definition of the term" in your previous email that initiated my 
response to you.

Best wishes,

Hadi Yaziji, M.D.
PhenoPath Laboratories


On Monday, October 13, 2003, at 03:00  PM, Nick Kirk wrote:

> Hadi
>  
> I am sorry but I must take issue with your very condescending and if I 
> may say so insulting tone.
>  
> For your information, I have over 18 years of experience doing IHC and 
> my lab does a considerable number of slides per day.
> I have set up the IHC service in two labs and have received much 
> praise for doing it.
> I have also done extensive lab based trials work for both DAKO and 
> Novocastra here in the UK as well, so I think my credentials are 
> better than most.
> I'm not at issue with the interpretation issue at all, that is indeed 
> a very skilled task that takes many years of study and experience to 
> become competent in.
> What I am taking issue with is the issues around clinical audit and 
> best practice.
> Now I don't know what clinical audit systems you have in your 
> establishment, but in ours it is regarded as poor clinical governance 
> i.e. bad practice by both myself, the Head Biomedical Scientist of the 
> department and all of my Pathologist colleagues not to have separate 
> controls per case.
> This is especially the case when you are reviewing tumour antigenicity 
> on samples that may come out of the archive.
> All our slides are stored in case order so to have positive controls 
> for each case actually makes it much easier the extract all the 
> relevant slides per case for later review. Having slides for the same 
> case filed in separate places introduces the potential for error, 
> especially when being initially filed.
> I know this to be true because it has happened to me on several 
> occasions where slides filed in different places have been mis-filed 
> and become difficult to retrieve.
> In the UK we use a system of evidence based good practice and evidence 
> suggests that is precisely what we are doing.
>  
> I hope that now explains it to you.
>  
> Nick Kirk BSc (Hons) FIBMS (I've got letters too)
> Head Biomedical Scientist
> Histopathology
> Hinchingbrooke Hospital
> Huntingdon
> Cambridgeshire
> England
>  
>
> -----Original Message-----
> From: histonet-admin <@t> lists.utsouthwestern.edu 
> [mailto:histonet-admin <@t> lists.utsouthwestern.edu]On Behalf Of Hadi 
> Yaziji
> Sent: 11 October 2003 16:22
> To: histonet <@t> pathology.swmed.edu
> Subject: Re: [Histonet] negative IHC controls
>
> Dear Nick,
>
> Thanks for the email. You definitely misread my email. First, where in 
> my message did I advocate not to use negative and positive controls 
> per case? Of course it's poor patient's care not to do that. Is it 
> necessary to run + and - controls on every antibody? I don't think so 
> provided you have the necessary experience to interpret them. To 
> address your other point about reviewing cases, we keep our positive 
> and negative controls indefinitely. You can always pull the controls 
> that pertain to the run of the particular day of the case in question.
>
> You will be 'dam fool' (I am copying your words) to run IHC if you 
> have no experience. That's much more dangerous legally and ethically. 
> I've seen slides misinterpreted where the positive control is present 
> on the same slide.
>
> Bottom line: one + control per run is adequate (provided you have the 
> experience, which I'm not sure you have based on your reply). One - 
> control per case is more than sufficient.
>
> I hope this addresses your concerns.
>
> Hadi Yaziji, M.D.
> PhenoPath Laboratories
>
>
> On Saturday, October 11, 2003, at 12:16 AM, Nick Kirk wrote:
>
> A cautionary note
>  
> I agree that false positives are rare but they do happen. We had a 
> couple a while ago when it turned out that the Teflon coat on the 
> probe of our DAKO Autostainer had perished and was carrying over 
> reagents from one slide to another and also contaminating our negative 
> control solution with primary antibody.
> Also they are very useful in checking that there is no endogenous 
> biotin activity (more common than people think) and also that your 
> hydrogen peroxide solution hasn't gone off when quenching endogenous 
> peroxidase activity.
>  
> As for the argument about only one positive control per antibody per 
> run rather than per patient -
> Well the question I would pose is this. If in 5 years time you wish to 
> review the immuno for a particular case, how do you ensure that the 
> staining quality was adequate at the time if there aren't any positive 
> controls for that case?
> On medico-legal grounds alone you should be doing positive controls 
> for each case, especially if those results end up with the patient 
> having a particularly aggressive treatment like chemotherapy or a 
> particularly invasive surgical procedure such as a colectomy or a 
> mastectomy. If someone wants to sue your organisation at a later date 
> for inappropriate treatment you need every bit of proof that your part 
> of the investigation was above reproach and controls is one thing that 
> will definitely be asked about. I certainly wouldn't like to stand up 
> in court and try and defend myself against that one!
>  
> Incidentally, we use Surgipath's Control slides which allow you (most 
> of the time depending on the size of the test section) to have the 
> positive control and test section on the same slide, which saves a lot 
> of space on the immunostainer and neatly solves the problem of where 
> do you store the positive control if you use the single control per 
> run model and you have multiple cases with the same antibody. It also 
> acts as a check that the slide has received the correct primary 
> antibody and that someone hasn't loaded the immunostainer wrongly.
>  
> At the end of the day I still go by the analogy someone else made here 
> earlier about airbags and seat belts in cars. Would you drive in a car 
> without them? They may never be needed in your entire driving life, 
> but you would be a dam fool not to have  them wouldn't you?
>  
> And I think we will have to agree to disagree Hadi, with your last 
> statement, it is poor quality control by any definition of the term, 
> not to use both negative and positive controls for each case.
>  
> Nick Kirk
> Histopathology
> Hinchingbrooke Hospital
> Huntingdon
> England
>
> -----Original Message-----
> From: histonet-admin <@t> lists.utsouthwestern.edu 
> [mailto:histonet-admin <@t> lists.utsouthwestern.edu]On Behalf Of Hadi 
> Yaziji
> Sent: 11 October 2003 03:07
> To: histonet <@t> pathology.swmed.edu
> Subject: Re: [Histonet] negative IHC controls
>
> Theoretically, I agree with you that (a) running multiple negative 
> control sections to cover the different antibodies/pretreatments is 
> ideal and (b) money should be well spent on QC (I can't emphasize that 
> enough). However, I honestly don't remember when was the last time 
> when I had a false positive staining on a patient's slide that the 
> negative control was the only way that allowed me to recognize the 
> false positive signal on the real slide. And we look at 100s of IHC 
> stains every day.
>
> Experienced pathologists and technologists can still recognize in > 
> 99% of the times a false positive signal from a real signal on the 
> tissue section of a given antibody without even having to look at 
> negative controls. I don't think it should be a CAP requirement at 
> all. In fact, I'd say the same thing on positive controls. All you 
> need is one positive control per antibody, but not one control/per 
> antibody/per patient. In many cases positive internal controls are 
> present on the same slide, so you can tell whether your antibody 
> worked simply by evaluating the expected positive internal controls. 
> In fact, if your positive 'external' control worked and internal 
> controls didn't, then you need to repeat your antibody test regardless 
> of the positive external control. External controls are different 
> tissues, fixed differently, processed differently and the tissue ages 
> differently (in terms of its antigenicity).
>
> Individuals who perform and interpret IHC studies must have the 
> knowledge to recognize the expected sub-cellular localization of every 
> antibody on every type of tissue, including aberrant signals. For 
> instance, you can easily dismiss a granular cytoplasmic TTF-1 signal 
> as not positive, because TTF-1 is a nuclear transcription factor and 
> we know it's expressed in the nuclei. However, hepatocellular 
> carcinomas can give you a consistent and reproducible granular and 
> cytoplasmic TTF-1 signal, and if you subsequently run confirmatory 
> markers (HepPar1, polyclonal CEA, CD10, etc.) they will be positive. 
> Such (granular cytoplasmic) signal should be recognized by the 
> interpreter (tech or pathologist) as a specific signal for tumors with 
> hepatoid phenotypes. This is just one of many examples..
>
> The bottom line: in real life, one negative control per case is more 
> than sufficient. And to say the least, it's inaccurate to state this 
> is poor patient care and lousy quality control.
>
> I look forward to any constructive criticism.
>
> Hadi Yaziji, M.D.
> PhenoPath Laboratories
>
> On Thursday, October 9, 2003, at 07:03 AM, Horn, Hazel V wrote:
>
> Not only should you be running a negative control for each patient 
> slide.   That negative control should be treated just as your antibody 
> is.   If the antibody is rabbit and antigen retrieved, so should your 
> control.   If another antibody on the same patient is mouse and not 
> retrieved another negative control should be run with this same 
> protocol.   In the United States, labs that are inspected by the CAP, 
> are required to run these controls.    MONEY should never be 
> considered as a reason to stop doing a part of a procedure.   It's 
> poor patient care and lousy quality control.   IMHO.
>  
> Hazel Horn, HT/HTL (ASCP)
> Histology Supervisor
> Arkansas Children's Hospital
>
> Phone - 501.364.4240
> Fax - 501.364.3912
>
>
> -----Original Message-----
> From: vermast [mailto:vermast <@t> rogers.com]
> Sent: Wednesday, October 08, 2003 3:57 PM
> To: histonet <@t> lists.utsouthwestern.edu
> Subject: [Histonet] negative IHC controls
>
>  
> I would like to get a feel for how many out there are running negative 
> control slides for IHC. 
>  
> In our lab we do just a handful of antibodies and initially I had been 
> running a negative control slide with each patient slide.   After much 
> discussion with our pathologists, we decided to omit these negatives 
> (which were conistently negative) and continue to just run a positive 
> control with each primary antibody for the run.  We use the Dako 
> autostainer and prediluted primaries.  The decision to stop running 
> negatives also coincided with Dako's decision to sell the negative 
> control sera separately from the primaries (they used to come packaged 
> together).  Perhaps I assumed that discontinuing to pair these 
> reagents together meant that few labs were using the negatives.
>  
> Anyhow, after having reviewed the last QMPLS (Canada) survey committee 
> comments, I believe the committe would like a negative control run 
> with each patient tissue slide in order to evaluate background  (they 
> have used NCCLS guide pages as reference).  Incidentally we weren't a 
> part of the survey due to a technicality.
> Any help or advice would be appreciated.
>  
> L. Vermast
> Stratford, Ont.
>
>
>
>
>
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>
>
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