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DIVISION OF HEMATOPATHOLOGY

HEMATOPATHOLOGY HANDBOOK FOR RESIDENTS AND FELLOWS

VOLUME 2

Revised July 5, 2006 STEVEN H. SWERDLOW, MD DIRECTOR, DIVISION OF HEMATOPATHOLOGY

TABLE OF CONTENTS VOLUME 2

FLOW CYTOMETRY LABORATORY EXPERIENCE ....................... 3 FLOW CYTOMETRY PANELS, AVAILABLE ANTIBODIES, GUIDELINES, TEST SPECIFICATIONS AND TEMPLATES............ 8

ICD9 CODES FOR FLOW .............................................................................................................. 18 FLOW CYTOMETRY WORKSHEET .................................................................................................. 19 FLOW CYTOMETRY REPORT................................................................................................. 22

IMMUNOHISTOCHEMISTRY .......................................................... 24

IMMUNOSTAINS/IN-SITU HYBRIDIZATION LABORATORY AND ORDERING INFORMATION .................... 25 STAINS FREQUENTLY USED IN HEMATOPATHOLOGY: CODES AND REACTIVITIES ............................ 27 COMPLETE IMMUNOHISTOCHEMICAL STAIN MENU/CODES ............................................................. 29

IHC/ISH REPORTING TEMPLATES ............................................... 35 STUDIES OF DNA CONTENT......................................................... 39 PEDIATRIC HEMATOPATHOLOGY AND GENERAL/SPECIAL HEMATOLOGY LABORATORY EXPERIENCE ............................. 43

PEDIATRIC HEMATOPATHOLOGY EXPERIENCE............................................................................... 44

GENERAL/SPECIAL HEMATOLOGY LABORATORY EXPERIENCE CHECKLIST 7-3-2006 ............................................. 46

D. MISCELLANEOUS TESTS .......................................................................................................... 50

PEDIATRIC HEMATOPATHOLOGY CHECKLIST ......................... 51 MOLECULAR DIAGNOSTIC AND CYTOGENETIC REQUISITIONS ......................................................................................................... 60 WEB-BASED RESOURCES............................................................ 69

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Flow Cytometry Laboratory Experience

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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 at the end of the core adult bone marrow rotation. This is also the opportunity to learn about flow cytometric DNA content study. The resident should report to Dr. F. Craig or her designate.

1. Meet with Dr. F. Craig 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. Review DNA content study procedures and results with Dr. L. Contis or designate 4. Complete checklist 5. Educational materials available. Flow Cytometry Self Study ­ Lecture, blue binder, Hematopathology Resource Room. Flow Cytometry Books ­ Bone Marrow Room, Flow Laboratory. "Flow Cytometry Articles" ­ Black binder, Hematopathology Resource Room

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Resident Flow Cytometry Rotation Checklist

Orientation with the Lead Technologist or her designate

Instrumentation Understand the principles of flow cytometric immunophenotyping.

Gain familiarity with instrument set ­up, compensation and quality control.

Antibody staining for immunophenotyping

Gain familiarity with procedures for surface and cytoplasmic antibody staining. Data Acquisition and Analysis for Immunophenotyping: Understand the principles of back-gating and dating using light scatter and antigen expression Understand the procedure for DNA / ploidy analysis

Know the immunophenotypic characteristics of the following entities:

Observed Actual Case Observed Teaching File Case Read About

Diagnosis/Finding Normal bone marrow Hematogones Reactive Lymph Node

Lymphoma

Follicular lymphoma Small lymphocytic lymphoma / chronic lymphocytic leukemia Mantle Cell lymphoma

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MALT lymphoma

Observed Actual Case Observed Teaching File Case Read About

Diagnosis/Finding

Burkitt lymphoma

T-cell lymphoma

Chronic leukemia

Hairy Cell Leukemia Prolymphocytic Leukemia, B-cell phenotype Prolymphocytic Leukemia, T-cell phenotype

Sézary Syndrome

Large Granular Lymphocytic Leukemia Adult T-cell Leukemia / Lymphoma

Acute Myeloid Leukemia

Acute Promyelocytic Leukemia Acute Myeloid Leukemia associated with t(8;21) Acute Myeloid Leukemia associated with inv(16) Acute Myeloid Leukemia with monocytic differentiation Acute Megakaryocytic Leukemia

Acute Lymphoblastic Leukemia

Precursor B-cell Precursor T-cell Minimal Residual Acute Lymphoblastic Leukemia Paroxysmal Nocturnal Hemoglobinuria

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UTILIZED THE FOLLOWING FLOW CYTOMETRY RESOURCES

Flow Cytometry Self Study ­ Lecture, blue binder, Hematopathology Resource Room. Flow Cytometry Books ­ Bone Marrow Room, Flow Laboratory: Clinical Flow Cytometry (Principles and Application) ­ Kenneth D. Bauer, Ricardo E. Duque, T. Vincent Shankey, Williams & Wilkins 1993 Flow Cytometry in Clinical Diagnosis, David F. Keren, American Society of Clinical Pathology, 3rd Edition, 2001 Flow Cytometry Principles for Clinical Laboratory Practice ­ Marilyn Owens, Michael R. Loken, Wiley-Liss, 1995 "Flow Cytometry Articles" ­ Black binder, Hematopathology Resource Room

I have completed the Flow Cytometry Checklist and reviewed it with Dr. Craig or her designate. Name ________________________ (printed) ________________________ (Signature) Date ______________________

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Flow Cytometry Panels, Available Antibodies, Guidelines, Test Specifications and Templates

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Full Four-Color Flow Cytometry Panels and Standard Extra's

Lymphoproliferative Panel (PB or LN)

FITC PE PerCP-Cy5.5 APC CD14 CD45 Kappa Lambda CD20 CD10 FMC-7 CD23 CD19 CD5 CD16/57 CD7 CD3 CD56 CD2 CD8 CD3 CD4 Add TdT / CD3 for Pediatric Lymphoproliferative

Lymphoproliferative Panel (BM)

FITC CD14 CD38 Kappa FMC-7 CD16/57 CD2 PE CD13/33 CD22 Lambda CD23 CD7 CD8 PerCP Cy5.5 CD45 CD20 CD20 CD19 CD3 CD3 APC CD34 CD10 CD10 CD5 CD56 CD4

Myeloma Panel

FITC CD14 CD38 Kappa CD16/57 CD2 CD3 Cyto-K PE CD13/33 CD22 Lambda CD7 CD8 CD138 Cyto-L PerCP Cy5.5 CD45 CD20 CD19 CD3 CD3 CD19 APC CD34 CD10 CD5 CD56 CD4

T-cell Extra

FITC TCR / PE TCR / PerCP Cy5.5 APC CD3 CD25

Also available: CD52 FITC for consideration for CAMPATH therapy.

CLL Extras

FITC ZAP70 PE CD38 CD19 PerCP Cy5.5 APC CD19 CD5 CD3 CD5

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Hairy Cell Extras

FITC CD103 CD22 Blkd. K PE CD22 CD11c Blkd. L PerCP CD19 CD20

MDS / Cytopenias (PB)

FITC CD14 CD38 Kappa CD16/57 CD2 PE CD13/33 CD22 Lambda CD7 CD8 PerCP Cy5.5 CD45 CD20 CD19 CD3 CD3 APC CD34 CD10 CD5 CD56 CD4

MDS / Cytopenias (BM)

FITC CD14 CD38 Kappa CD16/57 CD2 CD36 CD15 CD7 CD16 PE CD13/33 CD22 Lambda CD7 CD8 CD64 CD33 CD13/33 CD13 PerCP Cy5.5 CD45 CD20 CD19 CD3 CD3 CD45 CD117 CD19 CD11b APC CD34 CD10 CD5 CD56 CD4 CD34 HLA-Dr CD56 CD34

Acute Leukemia Panel (PB and BM)

FITC CD14 CD38 Kappa CD2 CD36 CD15 CD7 CD16 TdT PE CD13/33 CD22 Lambda CD8 CD64 CD33 CD13/33 CD13 MPO PerCP Cy5.5 CD45 CD20 CD19 CD3 CD45 CD117 CD19 CD11b CD3 APC CD34 CD10 CD5 CD4 CD34 HLA-Dr CD56 CD34 CD34

FEC Revised: 4/14/2006

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Limited Four-Color Adult Flow Cytometry Panels

Mini (B) Acute Lymphoblastic Leukemia PB or BM Previous diagnosis of B-lineage acute lymphoblastic leukemia (ALL) established at UPMC-Presbyterian/Shadyside including flow cytometric evaluation (NOT flow only). PB or BM submitted for evaluation of ALL. Review previous phenotype for additional aberrant markers. FITC CD14 CD38 Kappa CD34 TdT PE CD13/33 CD22 Lambda MPO PerCP Cy5.5 CD45 CD20 CD19 CD19 (PC5) CD3 APC CD34 CD10 CD5 CD34

Mini (T) Acute Lymphoblastic Leukemia PB or BM Previous diagnosis of T-lineage acute lymphoblastic leukemia (ALL) established at UPMC-Presbyterian/Shadyside including flow cytometric evaluation (NOT flow only). PB or BM submitted for evaluation of ALL. Review previous phenotype for additional aberrant markers. FITC PE CD14 CD13/33 CD38 CD22 CD2 CD8 CD7 CD13/33 TdT MPO CD1a as required PerCP Cy5.5 CD45 CD20 CD3 CD5 CD3 APC CD34 CD10 CD4 CD56 CD34

Mini (AML) Leukemia PB or BM Previous diagnosis of acute myeloid leukemia (AML) established at UPMCPresbyterian/Shadyside including flow cytometric evaluation (NOT flow only). PB or BM submitted for evaluation of AML. Review previous phenotype for additional aberrant markers. FITC CD14 CD38 CD2 CD15 PE CD13/33 CD22 CD8 CD33 PerCP Cy5.5 CD45 CD20 CD3 CD117 APC CD34 CD10 CD4 HLA-Dr

The following tube will be added if previous aberrant phenotype identified. CD7 CD13/33 CD19 CD56

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Basic PB or BM 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. FITC CD14 CD38 Kappa PE CD13/33 CD22 Lambda PerCP Cy5.5 CD45 CD20 CD19 APC CD34 CD10 CD5

Mini B-cell Lymphoma Follow-up on PB or BM: Limited evaluation for follow-up of B-cell lymphoma with previous diagnosis at UPMCPresbyterian/Shadyside including flow cytometric evaluation (NOT flow only). PB or BM submitted for evaluation of lymphoma, and morphology review is consistent with that diagnosis and does NOT demonstrate another disease process e.g. increased blasts. FITC CD14 CD38 Kappa PE CD13/33 CD22 Lambda PerCP Cy5.5 CD45 CD20 CD19 APC CD34 CD10 CD5

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 if this is indicated in the molecular or cytogenetic area of the requisition).

Mini CLL Follow-up PB or BM: Limited evaluation for follow-up of chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL) with previous diagnosis at UPMC-Presbyterian/Shadyside 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. FITC FMC-7 (-) ZAP70 Kappa PE CD23 CD38 CD19 Lambda PerCP Cy5.5 CD19 CD19 CD3 CD20 APC CD5 CD5 CD5 CD10

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Mini B-cell FNA: Preliminary evaluation of an FNA specimen with NO previous diagnosis, but cytological concern for lymphoma. Consider back-gating on CD19 to identify cells of interest or adding CD45 / CD14 for gating. FITC Kappa

or

PE PerCP Cy5.5 APC Lambda CD20 CD10 Lambda CD19 CD5

Kappa

Mini Myeloma Panel: Limited evaluation for follow-up of plasma cell neoplasm with previous diagnosis at UPMC-Presbyterian/Shadyside including flow cytometric evaluation (NOT flow only). PB or BM submitted for evaluation of plasma cell neoplasm, and consistent morphology, and morphology review is consistent with that diagnosis and does NOT demonstrate another disease process e.g. increased blasts. FITC CD14 Kappa CD16/57 CD3 Cyto-K PE CD13/33 Lambda CD7 CD138 Cyto-L PerCP Cy5.5 CD45 CD20 CD3 CD19 APC CD34 CD10 CD56

FEC Revised 4-14-2006

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Antibodies Available in the Flow Lab

FITC CD1 CD2 CD3 CD4 CD5 CD7 CD8 CD10 CD11b CD11c CD13 CD14 CD15 CD16 CD19 CD20 CD22 CD23 CD25 CD26 CD33 CD34 CD36 CD38 CD43 CD45 PE X X X X X X X X X X X X X PerCPCY5.5 PerCP PC5 APC CD45RA CD45RO CD52 CD55 CD56 CD57 CD59 CD61 CD79a CD103 CD117 CD138 Alpha-beta Gammadelta Glyco-A Bcl2 FMC7 HLA-DR Poly Kappa Poly Lambda MPO TdT Zap70 Simulset FITC X X X X X X X X X X X X X X X X X X X X X X X Kappa CD45 X X X PE PerCPCY5.5 PerCP PC5 APC

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

Lambda CD14

3-27-2006

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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. All Pediatric flow decisions. b. 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. c. There are questions about any of the information available (including the history, clinical information, test requested or morphologic appearance). d. For whatever reason, there is uncertainty regarding the appropriate panel. e. 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. 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. ii. 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 completed case is being tubed. 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 attached 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. 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 extras.

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University of Pittsburgh Medical Center Health System ­ Oakland Laboratories TEST SPECIFICATIONS: CLINICAL FLOW CYTOMETRY LABORATORY Leukemia Panels, CLL/Lymphoma Panels and T Lymphocyte Panels DELIVER ALL SAMPLES DIRECTLY TO THE FLOW CYTOMETRY LABORATORY Scaife Hall Room S763 (7th floor) 3550 Terrace Street Pittsburgh, PA 15261 (412) 624-3746 FLOW CYTOMETRY LAB HOURS OF OPERATION: Monday through Friday: 8:00 am to 6:00 pm. Emergency specimens can be processed on Saturday. The laboratory must be notified by 1 pm and the specimens must arrive by 2 pm. For Saturday emergency specimens, please page the clinical pathology resident at (412) 572-5851. The hematopathologist on call can be reached through the UPMC Oakland operator at (412) 647-2345. 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. LEUKEMIA, CLL/LYMPHOMA PANEL: 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 which support a neoplastic rather than reactive proliferation. Specimen Requirements: Bone marrow aspirate: Peripheral blood:

Minimum of 2 ml in a heparinized (green top) tube. One completely filled EDTA (preferred; purple top) tube or heparinized (green top) tube. NOTE: Peripheral blood or bone marrow blast count or target population should be at least 25%. If bone marrow, send one nonheparinized, unstained bone marrow slide if possible.

Lymph nodes:

Preferably 1 cm3 fresh tissue in saline or any tissue media. A small portion of all tissues (or other tissues) will be processed for histologic sections. Require a minimum of approximately 100,000 cells (e.g. 100 cells/ul x 1 ml; 10 cells/ul x 10 ml). 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.

Body fluids:

Fine needle aspirates:

Special Instructions: · In all cases, notify the lab before the specimen is sent (412 624-3746). If possible, notify lab one day in advance. · Specimens must be received by 5:00 pm on Fridays, and by 3 pm the day before a holiday. If a late arrival is anticipated, please call the laboratory to confirm that the test can be performed.

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·

Send a completed requisition. Send all specimens at room temperature. Use adequate safety measures in transporting specimens. T-LYMPHOCYTE TEST SPECIFICATIONS: Test Description: This test may be identified as T Cell Subsets, T and B Cells, T4/T8 counts and other synonyms. The complete CDC recommended 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. However, this is not endorsed by the CDC. Specimen Requirements: One completely filled EDTA (purple top) tube or two BD microtainer (purple top) pediatric tubes. Store sample at room temperature. DNA BY FLOW ANALYSIS: Test Description: This test may be identified as DNA ploidy, DNA/cell cycle analysis, and DNA analysis of cells. This test involves the examination of cellular DNA content. A DNA index is established for diploid and aneuploid cells in tumors, in addition to providing cell cycle statistics. This testing is sent to a reference laboratory. Specimen Requirements: Whole blood: 10 ml yellow (ACD), purple (EDTA) or green (heparin) anticoagulated venous blood kept at ambient temperature and analyzed within 24 hours of drawing. Bone marrow: 1 ml heparinized marrow kept at ambient temperature and analyzed within 24 hours of collection

CONTACTS, DIVISION OF HEMATOPATHOLOGY:

Steven H. Swerdlow, M.D. Fiona Craig, M.D. Judith Bright Karen Freilino Director, Division of Hematopathology Director, Flow Cytometry Laboratory Supervisor, Special Hematology Lead Technologist, Flow Cytometry (412) 647-5191 (412) 647-8504 (412) 624-2167 (412) 624-0394

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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 Hodgkins 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

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Flow Cytometry Worksheet File Name: DOE J

G1 8902 89.0% G2 9460 94.6% Control: G3 Value Result 5 Within reference range 81 Within reference range

Specimen: 003

G3 3580 35.8%

Run date: 11-Feb-04

Average gated events: Percent gated events:

Gates in regions: R1: G1,G2 Controls CD19 Control (CD3/CD19,UL) CD3 Control (CD3/Cd19, LR

Worksheet Calculations Kappa B cell subset Lambda+ B cell subset Kappa:Lambda CD19+ Bcell (from 5/10/19 tube) CD19+/CD5+ B cell subset CD20+ B cell (from K/L/20 tube) CD19+/CD10+ (PE) B cell subset (from 5/10/19) CD10 only (CD19-/CD10+) CD22+ B cells (from CD10/22/20 tube) CD2+ t cell CD3+ T cell Cyto CD3+* T cell CD5+/CD19- T cell CD7+ T cell CD4+/CD8- T helper CD8+/CD4- T cytotoxic/suppressor CD4+/CD8+ T cell subset CD4:CD8 T-helper:suppressor ratio CD16, CD56+/CD3+ T cell subset CD16, CD56+/CD3- NK cell other CD56+ CD13, CD33+ Myeloid, monocyte CD14+ Myeloid, monocyte CD15+ Myeloid CD33+ Myeloid, monocyte CD34+ Stem cell CD34+/CD13,CD33+ Immature myeloid, monocyte Myeloperoxidase* CD117+ Myeloid stem cell CD45+Leukocytes HLA-DR+ B,Myeloid,Activated T TdT+* TdT+/Cyto CD3+* CD19+/CD13,33+ CD7+/CD13,33 IgG2a F/IgG2a PE,UL IgG2a F/IgG2a PE,UR

R1

0.6 0.5 1.1 95 0 2 2 0 93 5 4 3 3 5 2.0 1.9 0.1 1.0 2 3 1 3 2 45 1 1 0 1 2 100 97 75 0 2 0 1.2 1.8

Alert

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File Name: DOE J

Specimen: 003

Run date: 11-Feb-04

0.2 0.9 2.1 0.1 0.2 1.6 0.5 2.5 1.2 0.6 1.6 0.3 0.1 0.1 1.5 0.2 0.1 0.2 1.4 0.1 0.0 0.0 0.0 0.0 0.0 95 1 1 4 N/F N/F N/F N/F N/F N/F N/F N/F N/F N/F N/F N/F N/F N/F N/F N/F N/F N/F N/F N/F N/F N/F N/F

IgG2a F/IgG2a PE,LR IgG1 PC5/IgG2a PE,UL IgG1 PC5/IgG2a PE,UR IgG1 PC5/IgG2a PE,LR IgG1 PC5/IgG2a F,UL IgG1 PC5/IgG2a F,UR IgG1 PC5/IgG2a F,LR IgM F/IgG2a PE, UL IgM F/IgG2a PE, UR IgM F/IgG2a PE, LR IgG1 F/IgG1 PE, UL IgG1 F/IgG1 PE, UR IgG1 F/IgG1 PE, LR IgG2 PCP/IgG1 PR, UL IgG2 PCP/IgG1 PR, UR IgG2 PCP/IgG1 PR, LR IgG1 PCP/IgG1 F, UL IgG1 PCP/IgG1 F, UR IgG1 PCP/IgG1 F, LR Cyto IgG1 FITC/Cyto IgG1 PerCP, UL Cyto IgG1 FITC/Cyto IgG1 PerCP, UR Cyto IgG1 FITC/Cyto IgG1 PerCP, LR Cyto IgG1 FITC/Cyto IgG2a RE, UL Cyto IgG1 FITC/Cyto IgG2a RE, UR Cyto IgG1 FITC/Cyto IgG2a RE, LR CD19+ B cell (from 34/13+33/19 tube) Cd20+ B cell (from CD10/CD22/CD20 tube) CD20+/CD10+ (FITC) B cell subset (from 10/22/20 tube) CD5+ T cell Kappa+ (Blocked) B cell subset Lambda+ (Blocked) B cell subset Kappa:Lambda (Blocked) Cyto Kappa+* B cell subset, plasma cells Cyto Lambda +* B cell subset, plasma cells Cyto Kappa:Cyto Lambda CD20+ B-cell (from blocked K/L/20) CD43+/CD19+ B cell subset CD22+ B cells (from 22/11c/25 tube) CD23+ B cell subset FMC7+ B cell subset CD138+ Plasma cells CD19+/CD38+ BCL2+/CD10+* BCL2+/CD20+* CD3+ T cell CD3+ T cell CD4+/CD45RO+ T helper memory CD4+/CD45RA+ T helper naïve CD16, CD56+/CD3+ T cell subset CD16, CD56+/CD3- NK cell, other CD56+/CD3+ NK-like T cell CD56+/CD3- NK cell, other

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File Name: Doe J

Specimen: 003

Run date: 11-Feb-04

N/F N/F N/F N/F N/F N/F N/F N/F N/F N/F N/F N/F N/F N/F N/F N/F N/F N/F N/F N/F N/F N/F

CD16+/CD3+ CD16+/CD3CD56+/CD3+ CD56+/CD3CD3+/Anti-TCR-alpha,beta+ T cell subset CD3+/Anti-TCR-gamma,delta T cell subset CD57+ Total CD3+CD25+ Activated T cell CD61+ Megakaryocytes, platelets Glycophorin A+ Total RBC CD 103+ B and T cell subsets CD 11c+ Monocytes, lymphocytes CD 25+ IgG1 F Blocked/IgG1 PE Blocked UL IgG1 F Blocked/IgG1 PE Blocked UR IgG1 F Blocked/IgG1 PE Blocked LR IgG1 PCP Blocked/IgG1 PE Blocked, UL IgG1 PCP Blocked/IgG1 PE Blocked, UR IgG1 PCP Blocked/IgG1 F Blocked, LR IgG1 PCP Blocked/IgG1 F Blocked, UL IgG1 PCP Blocked/IgG1 F Blocked, UR IgG1 PCP Blocked/IgG1 F Blocked, LR Comments:

Technologist:_______________________________ Pathologist:__________________________ Date: _______________________________ Date: ________________________

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FLOW CYTOMETRY REPORT

Results:

Cell suspension immunophenotypic studies were performed on # and # region(s) was/were analyzed. Region 1 represents the #. (#% of the events) Region 2 represents the #. (#% of the events) Region 3 represents the #. ( #% of the events) VIABILITY: # WBC: # x 109/L (uncorrected) -----------------------------B Cells---------------------R1-----R2 Antigen+ Usual Specificity # # # # # # # # # # # # # # # % Positive # # # # # # # # # # # # # # #

Kappa+....................B cell subset................. Lambda+...................B cell subset................. Kappa:Lambda............................................ Cytoplasmic Kappa+*.......B cell subset, plasma cells... Cytoplasmic Lambda+*......B cell subset, plasma cells... Cytoplasmic Kappa:Cytoplasmic Lambda*................... CD19+.....................B cell........................ CD19+/CD5+................B cell subset................. CD20+.....................B cell........................ CD10+.....................B cell subset................. CD43+/CD19+...............B cell subset................. CD22+.....................B cells....................... CD23+.....................B cell subset................. FMC7+.....................B cell subset................. CD138+....................Plasma Cells..................

-----------------------------T cells---------------------R1-----R2 Antigen Usual Specificity # # # # # # # # # # # # # # # # # # # # # # # % Positive # # # # # # # # # # # # # # # # # # # # # # #

CD1+......................Thymocyte..................... CD2+......................T cell........................ CD3+......................T cell........................ Cyto CD3+*................T cell........................ CD5+/CD19-................T cell........................ CD7+......................T cell........................ CD4+/CD8-.................T helper...................... CD8+/CD4-.................T cytotoxic/suppressor........ CD4+/CD8+.................T cell subset................. CD4:CD8...................T helper:suppressor ratio..... CD4+/CD45RO+..............T helper memory............... CD4+/CD45RA+..............T helper naïve................ CD16,CD56+/CD3+...........T cell subset................. CD16,CD56+/CD3-...........NK cell, other................ CD16+/CD3+................NK-like T cell................ CD16+/CD3-................NK cell, other................ CD56+/CD3+................NK-like T cell................ CD56+/CD3-................NK cell, other................ CD56+................................................... CD3+/Anti-TCR-alpha,beta+......T cell subset............ CD3+/Anti-TCR-gamma,delta1+....T cell subset............ CD57+ Total...............T cell subset, NK............. CD3+/CD25+................Activated T cell..............

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-----------------------------Myeloid---------------------R1-----R2 Antigen Usual Specificity % Positive # # # # # # # # # # # # # # # # # # # #

CD13,CD33+................Myeloid,monocyte.............. CD14+.....................Myeloid,monocyte.............. CD15+.....................Myeloid....................... CD13+.....................Myeloid....................... CD33+.....................Myeloid,monocyte.............. CD34+.....................Stem cell..................... CD34+/CD13,33+............Immature myeloid,monocyte..... CD61+.....................Megakaryocytes,platelets...... Myeloperoxidase..........Myeloid....................... CD117+....................Myeloid stem cell.............

------------------------Additional Antibodies------------R1-----R2 Antigen Usual Specificity # # # # # # # # # # % Positive # # # # # # # # # #

CD45+.....................Leukocytes.................... HLA DR+...................B,Myeloid,Activated T......... CD103+....................B and T cell subsets.......... CD11c+....................Monocytes,lymphocytes......... CD25+.....................Activated lymphocytes......... TdT+*.....................Lymphoblasts(myeloblasts)..... TdT+*/CytoCD3+*...........T lymphoblasts................ Glycophorin A+ Total......RBC........................... CD19+/CD13,33+.......................................... CD7+/CD13,33+...........................................

* The gates used for these antibodies may differ from those used for the other antibodies because of different fixation and/or permeabilization procedures. Cytoplasmic staining denoted with a "Cyto" can detect both surface and cytoplasmic expression. Antigen/Antibody CD1/BL6 CD2/S5.2 CD3/SK7 CD4/SK3 CD5/L17F12 CD5/BL1a CD7/4H9 CD7/8H8.1 CD8/SK1 CD10/SS2/36 CD11c/S-HCL-3 CD13/L138 CD14+/MOP9 CD15/PM81 CD15s/CSLex1 CD16/B73.1 CD18/L130 CD19/J4.119 CD20/L27 CD22/S-HCL-1 CD23/EBVCS-5 CD25/3G10 CD33/P67.6 CD34/8G12 CD43/DF-T1 CD45/2D1 CD45RA/L48 CD45RO/UCHL-1 CD56/Ncam-16.2 CD56/MY31 CD57/HNK-1 CD61/RUU-PL7F12 CD103/B-ly7 CD138/B-B4 Glycophorin A/D2.10 HLA-DR/L243 FMC7/FMC7 Kappa/TB 28-2 Lambda/1-155-2 MPO/H-43-5 TCR1,alpha-beta/WT31 TCR,gamma-delta-1/11F2 TdT/HTdT-6

This test was developed and its performance characteristics determined by the Flow Cytometry Laboratory at the University of Pittsburgh Medical Center. It has not been cleared or approved by the U.S. Food and Drug Administration. The FDA has determined that such clearance or approval is not necessary. This test is used for clinical purposes. It should not be regarded as investigational or for research. This laboratory is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA) as qualified to perform high-complexity testing. The results of these studies should be used in the context of the clinical history, and routine morphologic analysis.

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Immunohistochemistry

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Immunostains/In-Situ Hybridization Laboratory and Ordering Information

Immunostain Turnaround Time Routine runs: All orders received before 2 pm are set up to be run on the next working day (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. Special circumstances: If you have a special need to have additional stains run, they may be able to do so if you have blanks and place them in the immunochemistry lab oven. The Immunohistochemistry Laboratory is located at CHP, 5 MT and personnel can be reached at 647-7663. A list of the antibodies we use most frequently is on Page 24, Volume 2 and a complete list with codes is on page 26, Volume 2. If a pathologist or house staff office has unstained slides and needs immunostains for the next day, they can order the stains and send/tube these slides down to the immuno lab after 2:00 PM PROVIDING THAT THEY TELEPHONE THE LAB AND ALERT THEM OF THE REQUEST. This will allow more rapid turnover of case material and enhance patient care. ORDERING OF IMMUNOSTAIN PANELS The stain panels AHODPP, AMPAN, AHEP, APTLD must now be ordered as Stain/Process Group Protocols. (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 (AHODPP, AMPAN, AHEP or APTLD) 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.

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Enter the abbreviation for the Protocol (AHODPP, AMPAN, AHEP or APTLD) 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. 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 on Volume 2, page 32 should always be utilized and follows the general microscopic description.

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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. Most are obvious; some are not... Antigen / Marker CD1a CD2 CD3 CD4 CD5 CD7 CD8 CD10 (CALLA) C/S Codename ACD1 ACD2 ACD3 ACD4 ACD5 ACD7 ACD8 ACD10 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 R-S cells, CMV-infected cells, Some carcinomas B-cells Follicular dendritic cells, Some B-cells B-cells Follicular dendritic cells, SLL/CLL, Normal mantle cells R-S cells, Activated T & B-cells, Some lymphomas, Embryonal carcinoma Endothelium Blasts, Endothelium, Various mesenchymal neoplasms T-cells, Myeloid cells, B-cell subset, SLL/CLL, Mantle cell lymphoma, Other Bcell lymphomas, Not most follicular lymphomas All leukocytes B-cells, Plasmacytoid monocytes T-cells, Macrophages NK-cells, "NK-like" T-cells; Some malignant myeloblasts, lymphoblasts & plasma cells (multiple myeloma) NK-cells, Neural tissues, T-cell subset in follicles Monocyte/Macrophage, Many Melanomas! B-cells Blasts, Ewing Sarcoma Plasma cells, R-S cells, Some epithelial cells Anaplastic large cell lymphoma (systemic) Comment

CD15 (Leu-M1) CD20 (L26) CD21 CD22 CD23 CD30 (Ki-1/BerH2) CD31 CD34 CD43

ALEUM1 AL26 ACD21 ACD22 ACD23 ACD30 ACD31 ACD34 ACD43

CD45 (LCA) CD45RA (4KB5) CD45RO (UCHL-1) CD56

ALCA ACD45R AUCHL1 ACD56

CD57 (Leu 7) CD68 CD79a CD99 CD138 Alk-1

ALEU7 ACD68 ACD79 AEWING ACD138 AALK

Nuclear or nuclear and cytoplasmic stain.

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TIA-1 Granzyme B Clusterin Bcl-2

ATIA AGRANZ ACLUST ABCL2

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

Granular cytoplasmic stain

Cytoplasmic stain (actually mitochondrial) Nuclear stain (Don't call cytoplasmic stain positive) Nuclear stain

Cyclin-D1 (bcl-1) ACYCLD

Bcl-6

ABCL6

Bcl-10 Ki-67 (MIB-1) TdT(Terminaldeoxynucleotidyl Transferase) MPO (Myeloperoxidas e) Tryptase Neutrophil Elastase Kappa light chain Lambda light chain J chain Beta-F1 Glycophorin-A PAX5 Hodgkin's Disease Panel Small B-cell Panel EBV EBER-ISH AKI67 ATDT

Germinal center B-cells (follicular center cells); Many diffuse large B-cell lymphomas Aberrant nuclear expression in some MALT lymphomas. Proliferation marker (G1/S/G2/M phases) Lymphoblasts; Sometimes myeloblasts (<20%) Myeloid cells

Experimental Nuclear stain

AMPO

ATRYP ANE AKAPPA ALAMDA

Mast cells Neutrophils and their precursors Ig light chain kappa Ig light chain lambda Note the dropped "B" in the C/S code

AJ ABF1 AGLYP AHODPP

J chain of IgA & IgM Beta-F1 T-cell receptor chain on T-cells RBC's and their precursors B-cells (nuclear stain) LCA,CD3, CD20, CD15, CD30, EMA

SBCP

CD3, CD20, CD5, CD10, CD43, BCL-2, BCL-6, Cyclin D1 Epstein-Barr Virus Encoded mRNA (in situ hybridization) Ig light chain kappa mRNA (in situ hybridization) Ig light chain lambda mRNA (in situ hybridization) Kappa is black /Lambda is red-orange (antibody stain performed in in situ hybridization lab)

IEBER

Kappa mRNAISH Lambda mRNAISH Kappa/Lambda double stain

IRKAP

IRLAM

IKPLM

Experimental Order under Run Stain/Process Group Order under Run Stain/Process Group Order under Run Stain/Process Group Order under Run Stain/Process Group Order under Run Stain/Process Group Order under Run Stain/Process Group

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Complete Immunohistochemical Stain Menu/Codes

Name of Immunostain

34BE12 (CK 1 2 10 14/15 5) (IPEX) ABCL6 (IPEX) ACKIT (Histo) Actin All Muscle HHF35 (IPEX) Adenovirus (IPEX) Adhalin Frozen Adrenocorticotropic Hormone (IPEX) AE1 Cytoker. 10 14-16 19 (IPEX) AE3 Cytokeratin 1-8 (IPEX) Albumin (IPEX) alpha 1 Antichymotrypsin (IPEX) alpha 1 Antitrypsin (IPEX) alpha-Fetoprotein (IPEX) Alzheimer beta Amyloid (IPEX) Alzheimer Marker (IPEX) Amyloid A (IPEX) Amyloid kappa (IPEX) Amyloid lambda (IPEX) Amyloid P (IPEX) amyloid transthyretin prealbumin(IPEX) Anaplastic Lymphoma Kinase (IPEX) androgen receptor (IPEX) Anti-Thyroid Transc Factor (IPEX) B72.3 Tumor Glycoprotein (IPEX) Bcl-2 Oncoprotein (IPEX) BerEP4 (IPEX) BerH2 CD30 Hodgkin's (IPEX) Beta Catenin betaF1 T-cell Receptor (IPEX) BK Virus C1Q Complement (IPEX) C4d (IPEX) C5B-9 Memb. Att. Complex (IPEX) CA 125 Breast Marker (IPEX) CA 19.9 Pancreatic (IPEX) CA19.9 Calcitonin (IPEX) Caldesmon (IPEX) calponin Calretinin (IPEX) CAM 5.2 Cytokeratin 8 18 19 (IPEX) Cathepsin B (IPEX) Cathepsin D (IPEX) CD10 CALLA paraffin (IPEX) CD138 (IPEX) CD1a 010 (IPEX) CD2 T Lymphocytes (IPEX) CD20 B Lymphocytes (IPEX) CD21 Dendritic Cells (IPEX) CD22 B Lymphocytes CD23 Activated B/Dendritic Cells

Abb #1

AP903 ABCL6 ACKIT AAMA ADENOV AADHAL AACTH AAE1 AAE3 AALBU AAACT AAAT AAFP A4G8 AALZ50 AAMY AKAMY ALAMY AAMP APREA AALK1 AAR ATTF ATAG ABCL2 ABEREP4 AKI1 ABCATN ABF1 ABKV AC1Q AC4D APMAC ACA125 YCA199 ACA19.9 ACALCI ACALDES ACALP ACALRET ACAM ACAB ACAT ACD10 ACD138 ACD1A ACD2 CDMH ACD21 ACD22 ACD23

Abb #2

AP903 ABCL6 ACKIT AMAHHF35 Adeno AADHAL ACTH AAE1 AAE3 AALBU a1ACT a1ATryp AFP A4G8 AALZ50 AAMY AKAMY ALAMY AAMP APREA AALK1 AAR ATTF ATAG Bcl-2 ABEREP4 ACD30 ABCATN ABF1 ABKV C1q C4d C5B-9 MAC ACA125 YCA19.9 ACA19.9 ACALCI Caldesmon Calponin ACALRET CAM 5.2 ACAB ACAT CD10 CD138 CD1a ACD2 CD20 CD21 ACD22 ACD23

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CD3 T Lymphocytes (IPEX) CD30 BerH2 KI1 (IPEX) CD 34 CD4 Helper T Lymphocytes (IPEX) CD4 Subset (IPEX) CD4 T Cell Subset (IPEX) CD43 L60 T Lymphocytes (IPEX) CD45RA B Lymphocytes (IPEX) CD5 T/some B Lymphocytes (IPEX) CD56 (N-CAM) D5 subclone of 123C3 (IPEX) CD68 Macrophage PGM1 (IPEX) CD7 T lymphocytes (IPEX) CD79a B Lymphocytes (IPEX) CD8 T Cell Subset (IPEX) CD-99 (IPEX) CDX2 CEA monoclonal (IPEX) CEA polyclonal (IPEX) chorionic gonadotropin beta (IPEX) Chromogranin (IPEX) CK19, Cytokeratin 19 CK8 Cytokeratin Clusterin Collagen IV (IPEX) COX2, Cyclooxygenase-2 cyclin D1 Bcl-1 (IPEX) CYTOKERATIN 17 cytokeratin 20 (IPEX) Cytokeratin 5/6 (IPEX) cytokeratin 7 (IPEX) Cytokeratin AE1 AE3 (IPEX) Cytomegalovirus (IPEX) Desmin(IPEX) E-Cadherin (ECH-6) (IPEX) Endothelial Marker CD31 (IPEX) Epidermal GF Receptor (IPEX) Epithelial Membrane Antigen (IPEX) Epstein Barr virus LMP1 Estrogen Receptor (IPEX) Ewing sarcoma 12E7 (IPEX) Factor XIIIa (IPEX) Fibrinogen (IPEX) Follicle Stim. Hormone (IPEX) gastrin (IPEX) Glial Fibrillary Acidic Protein (IPEX) Glucagon (IPEX) Glut-1 glycophorin A (IPEX) Granzyme B Gross Cystic Disease Fluid Prot.(IPEX) Growth Hormone (IPEX) H. pylori (IPEX) hemoglobin (IPEX) Hepatitis B Core (IPEX) Hepatitis B Surface (IPEX) Hepatitis C (IPEX) hepatitis delta virus (IPEX) hepatoma panel paraffin 8 stains (IPEX)

ACD3 ACD30 ACD34 ACD4 AOPD4 CD4ACD4 ACD43 ACD45R ACD5 ACD56 ACD68 ACD7 ACD79 ACD8 YCD99 ACDX2 ACEAM ACEA ABHCG ACROMO ACK19 ACK8 ACLUST ACOL4 ACOX2 ACYCLD1 ACK17 ACK20 ACK5/6 ACK7 AAE13 ACMV ADESMIN ECAD ACD31 AEGFR AEMA AEBV AER AEWING AXIII AFIB AFSH AGAST AGFAP AGLUC AGLUT AGLYP AGRANZB AGCDFP AGH HPYL AHBG AHBCOR AHBS AHEPC AHBDTA AHEP

CD3 CD30 KI-1 CD34 CD4 ACD4 AOPD4 CD43 CD45 ACD5 ACD56 CD68 PGM1 ACD7 CD79a CD8 CD99 ACDX2 ACEAM CEA BHCG Chromogran CK19 ACK8 ACLUST ACOL4 ACOX2 ACYCLD1 Cytoker 17 ACK20 ACK5/6 CK7 AE1/3 CMV Desmin E-Cad CD31 AEGFR EMA EBVLMP1 AER Ewing12E7 FactorXIII Fibrinogen AFSH AGAST GFAP Glucagon Glut1 AGLYP AGRANZB AGCDFP AGH H. pylori AHBG HBVCore HBVSurface AHEPC AHBDTA AHEP

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HepPar 1 Hepatocytes (IPEX) Her-2/neu (IPEX) Her-2/neu c-erb (IPEX) Hercept Test (IPEX) Herpes Simplex Virus I & II (IPEX) HMB45 Melanoma (IPEX) HPV Papilloma Virus (IPEX) Immunoglobulin A (IPEX) immunoglobulin D (IPEX) Immunoglobulin G (IPEX) Immunoglobulin M (IPEX) Inhibin Alpha (IPEX) Insulin (IPEX) Interleukin2 (IPEX) J chain of IgA+IgM (IPEX) Kaposi Sarcoma (IPEX) Kappa amyloid (IPEX) Kappa Light Chain (IPEX) KI67 Proliferating Cells (IPEX) L26 B lymphocyte (IPEX) Lambda Light Chain (IPEX) Laminin (IPEX) LCA Pan Leukocyte (IPEX) LCA, CD45 Monoclonal (IPEX) Leu M1 CD15 (IPEX) Leu7 CD57 Natural Killer (IPEX) LN3 HLADR (IPEX) Lutenizing Hormone (IPEX) Lysozyme (IPEX) mac 387 macrophage (IPEX) Mast cell tryptase (IPEX) Melan A/Melanoma (IPEX) microtubule associated prot. (MHHS) MutL Homolog (IPEX) MutS Homolog 2 (IPEX) Myeloperoxidase (IPEX) Myogenin for Rhabdosarcoma (IPEX) Myoglobin (IPEX) Myosin Heavy Chain (IPEX) myosin paraffin (IPEX) Neurofilament (IPEX) Neuron Specific Enolase (IPEX) neutrophil elastase (IPEX) NKIC3 melanoma (IPEX) osteocalcin Osteonectin P16 (IPEX) P21, WAF1 P504S (IPEX) P53 Tumor Suppressor Protein (IPEX) P57 (IPEX) P63 Tumor Suppressor Protein (IPEX) pancreatic polypeptide (IPEX) parathyroid hormone (IPEX) Parvovirus (IPEX) PAX5, B-cell Specific Activator Protein PGP 9.5 Neuroendocrine (IPEX) Pituitary Hormone alpha Chain (IPEX)

AHEPAR H2NMWHer-2/neu ANEU AHERCEPT AHSV12 AHMB45 AHPV AIGA AIGD AIGG AIGM AINHIB AINSU ACD25 AJ AHHV8 AKAPY AKAPPA AKI67 AL26 ALAMDA ALAM ALCA LCAMH ALEUM1 ALEU7 ALN3 ALH ALYSO AMC387 ATRYP AMELA ATAU AMLH1 AMSH2 AMPO AMYOGN AMYO ASMYOS AMYOS ANFIL ANSE ANE ANKIC3 AOC AON AP16 AP21 AP504S AP53 P57 AP63 APP APTH APARVO APAX5 APGP AAPIT

HepPar1 Her- 2/neu ANEU Hercept HSV1&2 HMB45 HPV IgA AIGD IgG IgM Inhibin Insulin ACD25 AJ AHHV8 AKAPY Kappa KI67 L26 Lambda Laminin LCA LCA LeuM1 CD57 LN3 ALH Lysozyme AMC387 Tryptase Melan A ATAU AMLH1 AMSH2 MPO Myogenin Myoglobin SMMHC AMYOS Neurofila ANSE ANE ANKIC3 AOC AON P16 AP21 AP504S P53 P57 P63 APP APTH Parvo APAX5 PGP AAPIT

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Placental Alkaline Phosphatase (IPEX) Pneumocystis carinii (IPEX) prion protein (IPEX) Progesterone Receptor (IPEX) Prolactin (IPEX) PROSTATE Specific Acid Phosphatase (Surg) prostatic alkaline phosphatase(IPEX) Prostatic Specific Antigen (IPEX) Renal Cell Ca (IPEX) Respiratory Syncytial Virus (IPEX) S100 (IPEX) Sarcomeric Actin (IPEX) Serotonin (IPEX) Smooth Muscle Actin IA4 (IPEX) Somatostatin (IPEX) surfactant protein A (IPEX) SV40 papova virus (IPEX) synaptophysin Terminal Deoxynucleotide Transferase (IPEX) Thrombomodulin (IPEX) Thyroglobulin (IPEX) TIA1 granzyme (IPEX) Toxoplasma (IPEX) Transforming Growth Factor Alpha (IPEX) Treponema pallidum TSH (IPEX) TTF-1 Tyrosinase ubiquitin (IPEX) UCHL1 CD45RO (IPEX) Ulex Europaeous Lectin (IPEX) Varicella zoster (IPEX) VEGF, Vascular Endothelial Growth Factor Villin Vimentin (IPEX) von Willebrand Factor 8 (IPEX) wide spectrum cytokeratin combo (IPEX) Wilms' Tumor 1 (IPEX)

APLAP APCAR APRP APR APRO PASP APAP APSA ARCC ARSV AS100 ASACT ASERO AACTIN ASOMAT ASPA ASV40 ASYNP ATDT ATHRMBO ATHYRO ATIA1 ATOXO ATGFA ATREP ATSH TTF ATYROS AUBQ AUCHL1 AULEX AVZV AVEGF AVILLIN AVIMEN AVWF APANKR AWT1

PLAP P.Carinii APRP APR APRO APSP APAP PSA ARCC ARSV S100 SarcActin Serotonin SMActin Somatostat ASPA ASV40 Synapto TdT ATHRMBO Thyroglob ATIA1 Toxoplasma ATGFA ATREP ATSH TTF-1 Tyrosinase AUBQ UCHL1 ULEX Varicella AVEGF VILLIN Vimentin Factor 8 APANKR AWT1

CODES FOR DOUBLE LABELING

ICKDE ICKAC ICKMI AE1/AE3 and desmin AE1/AE3 and actin (HHF35) 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)

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UPMC Anatomic Pathology Protocol for ordering EGFR (or other diagnostic histochemical, immunohistochemical and molecular tests) on ARCHIVED Specimens

I. Regulatory Background:

"Laboratory is permitted to use the date the specimen was retrieved from storage for testing as the Date of Service, instead of the Date of Collection"

Reference: Centers for Medicare and Medicaid Services Federal Register File Code CMS-3119-PN

"For laboratories subject to CLIA-88 regulations, verbal requests for laboratory tests are permitted only if the laboratory subsequently obtains written authorization for testing within 30 days. The laboratory must maintain the written authorization or documentation of efforts made to obtain a written authorization." Reference: Department of Health and Human Services, Health Care Financing Administration. Clinical laboratory improvement amendments of 1988; final rule. Fed Register. 2003(Jan 24):7162 [42CFR493. 1241(a),1241(b)]; "Does the laboratory have a policy that personnel receiving verbal or phone orders must read back the entire order to verify accuracy of transcription?" Reference: CAP Inspection checklist, Lab General, question: GEN.40935

II. PROTOCOL:

1. In Pathology, phone requests for studies (histochemical stains, immunostains, FISH tests or other anatomic pathology tests) on archived material (material on cases that are >30 from the date of accession) should be handled as follows:

PATHOLOGISTS SHOULD BE AWARE OF HOW THE SEQUENCE OF EVENTS OCCURS WHEN OBTAINING TESTING ON ARCHIVED CASES, BUT THE GOAL IS FOR CALLS TO BE FORWARDED TO THE OFFICE SUPPORT STAFF TO WALK THE REQUEST THROUGH OUR SYSTEM. IT IS BEST FOR ANYONE RECEIVING CALLS ABOUT ORDERING TESTS ON ARCHIVED CASES TO REFER THE CALLER TO THEIR PERSONAL PATHOLOGY SECRETARY OR, AS BACKUP, THE APPROPRIATE PUH RECEPTIONIST AT 647-3720 OR SHY RECEPTIONIST AT 632-2318 WHO WILL PERFORM THE STEPS BELOW AS THE "Receiver of phone request". a) Receiver of phone request should find case being requested for study in the AP LIS

system based on the clinician's information, and the receiver should identify the test being requested. The receiver of the phone MUST obtain the appropriate billing information (SEE STEP #3) and ordering physician information (See below).

b) Receiver of phone request should enter name of clinician making request (same as

clinician in Section II.2 below) into the "additional physician" field via COPATH PostSignout edit under the "Staff/Retrieval" tab. c) The receiver of the phone request must repeat back the entire order to the requester. d) The receiver of the phone request should inform the requester of the name of the appropriate pathologist and case number. e) The receiver of the phone request should ask the requester to provide a written request for the test (see policy "Criteria for the Non-Acceptance of Specimens): http://aplis.upmc.edu/intranets/Presby/procedure/04.htm and SEE STEP #2 Below.

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f)

The receiver of the phone request should send an email to Georgene Zemba and Jim Bird with the case number and test ordered (SEE STEP #4 Below).

g) The receiver of the phone request should now forward the request to the appropriate pathologist (signout pathologist). If the pathologist of record is unavailable, then the case should be triaged to the Medical Director. 2. GENERAL INFORMATION

a) To perform tests on archived specimens, a written request from the clinician is required

(preferably on the Pathology Requisition under Special Procedures). The requisition must specify the specific archived case number that is needed for further testing.

b) A verbal request is acceptable but the clinician is required to provide a written request

within 30 days of the verbal request. The pathologist ordering the test on archived material should document the clinician request in the addendum: "At the request of Dr. ___________ EGFR studies were performed on this archived patient specimen". 3. REGISTERING THE PATIENT

a) Clinician must have the patient registered in Medipac with current billing information.

This can be performed by fax.

The form is located at the following URL:

http://aplis.upmc.edu/intranets/Presby/forms/Registration%20Form-Outreach.pdf As indicated, the form should be faxed to lab outreach to complete registration. When a phone inquiry is made, the receiver of the call should inform the clinician that this registration process must occur. 4. BILLING THE PATIENT ACCOUNT

a) Georgene Zemba and Jim Bird must be informed via email of the CASE NUMBER and

TEST ORDERED so that a "Charge transfer" form can be completed and sent to charge processing to bill the test to the patient account created in #3 above. 5. SIGNOUT AND PAPERWORK FILING Pathologist should forward requisition (with Surgical Case number written on it) to Pathology receptionist for filing. 6. WHAT THE PATHOLOGIST NEEDS TO DO:

a) If call is received, refer the case to the secretaries per II.1 above. Because the

secretaries often have trouble identifying the case number on which the test is to be performed, it would be helpful for the pathologist to access COPATH, find the patient and specimen number, and order the desired test prior to transferring the call to the secretary who will be responsible for billing and reporting issues. b) If a case is sent to the pathologist by the secretary, that pathologist should order the test on that case per normal procedure in COPATH

c) Pathologist signs out addendum with test result. In that addendum, the pathologist should specifically state "At the request of Dr. XXXX, YYYY studies<insert name of study> were ordered. The results of these studies are ...................."

The pathologist should also indicate to the transcriptionist to make sure that the requesting physician is added to the "copies to" field in COPATH. Reports will automatically be autofaxed to clinician.

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IHC/ISH Reporting Templates

35

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

anti-kappa kappa mRNA-ISH anti-lambda lambda mRNA-ISH Double kappa/lambda anti-IgG anti-IgA anti-IgM anti-IgD CD20/L26 CD22 CD45R/4KB5 CD79a PAX 5 CD21 CD23 CD138 J chain bcl-2 bcl-6 bcl-10 CD10 MUM-1 cyclin D1 TdT CD45/LCA CD15/Leu M1 CD30/Ber H2 OCT-2 Bob.1 EMA ALK-1

Usual Reactivity

B-cell subset B-cell subset B-cell subset B-cell subset B-cell subset B-cell subset B-cell subset B-cell subset B-cell subset B-cells B-cells B-cells B-cells B-cells Follicular dendritic cells B-cell subset, follicular dendritic Plasma cells, other Plasma cells Lymph subset, other Follicular center cells, other Nuclear stain in B-cell lymphoma subset B-cell subset B-cell subset Mantle cell lymphoma Lymphoblasts, some myeloblasts Leukocytes Reed-Sternberg, myeloid RS, activated lymphs B-cells, other B-cells, other Epithelium, lymph subset Anaplastic large cell lymphoma kinase

Result

36

Clusterin CD1a CD2 CD3 CD4 CD5 CD7 CD8 CD45RO/UCHL-1 CD43/Leu 22 Beta-F1 CD56 CD57/Leu 7 TIA1 Granzyme B CD99 CD25 CD68/PGM-1 Myeloperoxidase Lysozyme Neutrophil elastase CD117 Tryptase CD34 Glycophorin A Factor VIIIRA Ki-67/MIB-1 P53 AE1/AE3 Cam 5.2 Pankeratin S100/S100a HMB-45 EBV-ISH (EBER) EBV-LMP Parvovirus CMV HHV8 H.Pylori

Anaplastic large cell lymphoma, other Thymocytes, Langerhans-type cells T-cells T-cells T-cell subset T-cells, B-cell subset T-cells, NK-cells T-cell subset Mostly T-cells T-cells, some B-cells, myeloid TCR-beta chain T-subset/Natural killer T-subset/Natural killer Cytolytic T-cells Cytotoxic cells Lymphoblasts, Ewing sarcoma Activated lymph, other Myeloid, marcrophages, some lymphs Myeloid Myeloid, marcophages Myeloid Immature myeloid Mast cells Progenitor cells, endothelial cells, other Red blood cells Megakaryocytes, endothelial cells Proliferating cells Tumor suppressor gene Cytokeratin Cytokeratin Cytokeratin Neural, melanoma & other Melanoma Epstein-Barr virus Epstein-Barr virus Parvovirus Cytomegalovirus Human herpes virus-8

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Template Report ­ Her 2/neu Oncoprotein

Immunoperoxidase staining has been performed for the Her 2/neu oncoprotein. Distinct complete membrane staining is identified in # % of tumor cells. This test scored as # of potential score of 3+ and is interpreted as positive/negative. Immunohistochemical assays for the Her 2/neu oncoprotein are evaluated using the following scheme. Score Pattern No staining is observed or membrane staining is observed in less than 10% of the tumor cells A fair/barely perceptible membrane staining is detected more than 10% of the tumor cells. The cells are only stained in part of their membrane; includes those cases with 1-10% complete membrane staining A weak to moderate complete membrane staining is observed in more than 10% of the tumor cells A moderate strong complete membrane staining is observed in more than 10% of the tumor cells Her 2/neu overexpression assessment Negative

0

1+

Negative

2+

Weak Positive

3+

Strong Positive

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Studies of DNA Content

39

Introduction to Studies of DNA Content (contact Dr. L. Contis).

1. During your lymph node experience contact Dr. Lydia Contis and ask her to show you any current cases that come in or to review a set of prior studies. Review basic technique used and purpose for these studies. Review Educational Resources Bone Marrow Pathology, Kathryn Foucar, 2nd edition, ASCP Press, 2001, page 497. Immunophenotyping Edited by Carleton C. Stewart and Janet K.A. Nicholson, 2002.

2.

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41

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Pediatric Hematopathology and General/Special Hematology Laboratory Experience

43

Pediatric Hematopathology and General/Special Hematology Laboratory Experience (~4 weeks)

Trainees should report to the pathologist signing out CHP bone marrows and to Dr. Kaplan at the start of the rotation. Trainees should also meet with Dr. Kaplan or her designate at the midpoint to review progress on the rotation and at the completion of the rotation. If Dr. Kaplan is not available, report to Dr. Contis. Inform the pathologist covering the general hematology laboratory as well.

Pediatric Hematopathology Experience

1. 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 Signout of CHP Marrows that have Biopsies". 2. Review of pediatric material from Automated Testing Laboratory and Flow Cytometry Laboratory A. Preview and sign out all pediatric abnormal smears and fluids with faculty hematopathologist. 3. 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, 5th Edition, WB Saunders, 1998. C. Pediatric Hematology/Oncology Journal

4. Review results of ancillary procedures performed on marrows you have reviewed and read addenda faculty issue (see procedure Volume 2, page 57. )

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Policy for Signout of CHP Marrows that have Biopsies

1. Hematopathology signs out biopsies on hematologic cases including non-Hodgkin lymphomas. CHP surgical pathology signs out the biopsies on tumor cases. On all cases with a biopsy, the histologic section must be reviewed by the hematopathologist even if it is not a case where the hematopathology is signing out the biopsy. This is to insure that it does not conflict with the aspirate smear evaluation. In all cases with a biopsy, where CHP is signing out the biopsy the hematopathologist should contact the CHP pathologist signing out the biopsy to make sure that the two diagnoses will not conflict. In some cases, this may involve jointly reviewing the case. The CLSI report should state "CHP BM biopsy labeled_____ was reviewed/discussed with________(name of pathologist)." If the biopsy is not available at the time of our signout, it should be so stated. The CHP report should also continue to document that the hematopathologist (state name) provided a second opinion.

2.

3.

Policy for Assignment of Marrow Cases without Biopsies

Marrow signout 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.

Policy for Signout of CHP Marrows with Insufficient Material for a Complete Diagnosis

1. Whenever an insufficient sample is received, please use the following diagnosis "LIMITED SAMPLE" and not "insufficient for diagnosis".

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General/Special Hematology Laboratory Experience Checklist 7-3-2006

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 and turned in to Dr. Swerdlow's office at the completion of the rotation.

1.

General Activities

Keep a notebook indicating which laboratory tests (routine and special) have been observed or reviewed following returns by the reference laboratories. Also keep a record of patients and abnormal PB and body fluid smears that you have seen. This should include relevant clinical information for each patient. Review each case with the pathologist assigned to the lab service. Also see section 2B below. Follow-up patients whom you have reviewed with abnormal peripheral bloods and body fluids to determine the significance of the abnormality on diagnostic and therapeutic decision making and ultimate clinical outcome. Review a spectrum of abnormal results. These should include: o o o o o Macrocytic and microcytic anemias Thrombocytopenia Granulocytosis and granulocytopenia Blasts in the peripheral blood Cases with intraleukocytic abnormalities as available, either as review specimens or in the study sets

If no cases of each of the above are available and you are in your last week, be sure to review teaching slides or other resources (ask Dr. Kaplan or designate for help if required).

2. Specific Activities General Hematology Laboratory (ATL)

The laboratory supervisor, Barbara Hill and the hematology lead technologists, Bill Wertz and Pam Nowak and chemistry lead, Linda Sendek will help you with hematology instrumentation and identification of abnormal materials that need to be reviewed.

A. General

Review procedure manuals in general hematology, coagulation and urinalysis including the procedures for operating the Yellow Iris. The purpose of this review is to learn how a procedure manual is constructed, to appreciate the NCCLS format and to learn how to find a procedure when needed. 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. Kaplan or designate.

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General Hematology B. Hematologic Microscopy

Review normal PB morphology, understanding variations between adult and pediatric values. (Review kodachrome sets located in room C918, 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 to see if there are reviewed slides (the pediatric bone marrow technologist will have these slides). When slides are designated, the trainee should obtain clinical information about the patient, then review the slide including performing a 100-200 cell differential for peripheral bloods 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 CLSI lab is often the first place where an abnormality is detected. The criteria used for red cell morphology classification can be found in the hard copy supplement. Peripheral Blood ­ smears reviewed Body Fluids ­ preparations reviewed Correlate body fluid results from cytology laboratory with hematology findings.

C. Automated Equipment: Coulter

1. Coulter Review procedure manual Observe: Setup/Cleaning of instrument QC/QA Procedures, graphing Operation of Coulter 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 dot plots on sheet "Coulter Printout" in the hard copy supplement. Learn to evaluate normal and abnormal patterns. Understand meaning of individual flags and mechanisms for evaluating flags. Know what a flag is.

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Urinalysis

2. Yellow Iris: Review procedure manual Observe set-up and urinalysis runs on the Yellow Iris Observe: Set up, preparation of reagents, samples QC/QA Procedures, graphing Running, evaluation of samples Review urine sediment images in Yellow Iris 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 Yellow Iris archive of abnormals Crystals and casts Cells

2. Coagulation automated equipment:

A. MLA-1800 Review procedure manual Observe: Set up, preparation of reagents, samples QC/QA Procedures, graphing 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. B. Mini Vidas for D-dimer Observe the D-dimer procedure and understand its clinical usage as a negative predictor for DVT's and as a positive indicator of DIC.

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Administrative Aspects of Laboratory

Attend the following laboratory meetings. Hematology Laboratory meetings, CLSI hematology library (contact Dr. Monaghan for times).

4. Special Hematology Laboratory

Most 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 C601 under Hematology References. Review Color Atlas of Hemoglobin Disorders: A compendium based on Proficiency Testing (located in C601) Understand principles of HPLC for hemoglobin separation Review tracings that come back from the reference laboratories.

C. 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 Teaching case /recent send out file Read about Osmotic fragility Teaching case /recent send out file Read about Heinz bodies Teaching case /recent send out file Read about

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D. 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 F. Other Hematology Testing:(Vitamin B12, serum and RBC folate, serum iron and ferritin)

These tests are now done in chemistry. Discuss how they are used in the workup of hematologic disorders with Drs. Monaghan/Contis. Review methodology utilized (see Linda Sendek). References: Color Atlas of Hemoglobin Disorders, A Compendium Based on Proficiency Testing.

James D. and Steven H. Kroft, Editors, 2003.

Clinical Diagnosis and Management by Laboratory Methods, John Bernard Henry. Haemaglobinopathy Diagnosis. Barbara Bain, Blackwell Science, 2001.

Before completing your rotation, please review the completed checklist with Dr. Monaghan, sign and turn into Dr. Swerdlow's office.

I have completed the General Hematology Laboratory Checklist and reviewed it with Dr. Monaghan.

_________________________________ RESIDENT/FELLOW NAME _______________________________ SIGNATURE ________ DATE

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Pediatric Hematopathology Checklist

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 Collin RD and Swerdlow SH, eds. Pediatric Hematopathology). Knows role of cytogenetic 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 Neoplastic hematologic diseases of the peripheral blood and bone marrow Precursor B-lymphoblastic leukemia / lymphoma (precursor B-cell ALL) Precursor T- lymphoblastic leukemia / lymphoma (precursor T-cell ALL) Acute myeloid leukemias AML with recurrent genetic abnormalities AML with t(8;21)(q22;q22) AML with abnormal bone marrow eosinophils inv(16) or t(16;16) Acute promyelocytic leukemia t(15;17) or variant AML with 11q23 (MLL) abnormality Acute myeloid leukemia and myelodysplastic syndromes, therapy-related

Observed Actual Case

Observed Teaching File Case

Read About

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Diagnosis / Finding AML not otherwise categorized AML minimally differentiated AML without maturation AML with maturation Acute myelomonocytic leukemia Acute monoblastic and monocytic leukemia Acute megakaryoblastic leukemia Myelodysplastic/myeloproliferative diseases Chronic myelomonocytic leukemia Chronic myelogenous leukemia Juvenile myelomonocytic leukemia Myelodysplastic syndromes Refractory anemia Refractory anemia with ringed sideroblasts Refractory anemia with excess blasts (RAEB 1 and -2) Bone Marrow involvement in lymphoma: Diffuse large B-cell lymphoma Burkitt lymphoma/leukemia Anaplastic large cell lymphoma Nodular lymphocyte predominant Hodgkin lymphoma Classical Hodgkin lymphoma

Observed Actual Case

Observed Teaching File Case

Read About

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Diagnosis / Finding

Observed Actual Case

Observed Teaching File Case

Read About

Other BM in posttransplant lymphoproliferative Disorder Bone Marrow Failure Syndromes Fanconi Anemia Dyskeratosis Congenita Schwachman-Diamond Syndrome Pearson Syndrome Amegakaryocytic Thrombocytopenia Reticular Dysgenesis Diamond ­ Blackfan Anemia Transient erythroblastopenia of childhood Congenital dyserythropoietic anemia Severe congenital neutropenia (Kostmann syndrome) Thrombocytopenia absent radii (TAR)

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Diagnosis / Finding

Observed Actual Case

Observed Teaching File Case

Read About

Down Syndrome Transient myeloproliferative disorder Acute megakaryoblastic leukemia Lymphohistiocytic Disorders Genetic hemophagocytic lymphohistiocytosis Secondary hemophagocytic lymphohistiocytosis X-linked lymphoproliferative disorder Langerhans Cell Histocytosis (Histiocytosis X) Storage Disease Gaucher Disease Niemann-Pick Disease Mucopolysaccharidoses Metastatic Tumor Neuroblastoma Rhabdomyosarcoma Ewing's Other Non Neoplastic Disorders Red Blood Cells Anemia

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Diagnosis / Finding

Observed Actual Case

Observed Teaching File Case

Read About

Iron Deficiency Anemia of chronic disease B12/folate deficiency Hemolytic Aplastic anemia Idiopathic Secondary Infection Associated

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Diagnosis / Finding

Observed Actual Case

Observed Teaching File Case

Read About

Drug/Toxins Thymoma Erythrocytosis Secondary to nonneoplastic conditions (renal) White Blood Cells Leukemoid Reaction / Neutrophilia Infection Drugs Inflammatory Disorders Neutropenia Drug induced Reactive NK/large granular lymphocytes Constitutional disorder Eosinophilia Basophilia Monocytosis Lymphocytosis Infectious mononucleosis Megakaryocytes / Platelets Thrombocytosis Thrombocytopenia Drugs/Toxins Infection

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Diagnosis / Finding Immune mediated Constitutional disorders Bernard Soulier Syndrome May-Hegglin Anomaly Gray Platelet Syndrome Idiopathic thrombocytopenic purpura Thrombotic thrombocytopenic purpura Disseminated intravascular coagulation Hemolytic uremic syndrome

Observed Actual Case

Observed Teaching File Case

Read About

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PRESENTED THE FOLLOWING PEDIATRIC BONE MARROW OR LYMPH NODE CASES (Submit Presentation in Portfolio.)

PHB NUMBER

DIAGNOSIS

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UTILIZED THE FOLLOWING BONE MARROW RESOURCES

Swerdlow SH, Collins RD Pediatric Hematopathology, Churchill Livingstone, 2001. Nathan, DG and Orkin, SH, Nathan and Oski's Hematology of Infancy and Childhood, 5th Edition, WB Saunders, 1998.

Pediatric Hematology/Oncology Journal

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 and reviewed it with Dr. Contis or her designate. Name ________________________ (printed) ________________________ (Signature) Date ______________________

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Molecular Diagnostic and Cytogenetic Requisitions

Request on BM specimens should be given to BM techs. On lymph node service, please fax requisition and save with fax "receipt" in notebook in room C603. It is also preferred that you call to inform them a fax is coming. Lymph node assistant or backup can help.

Additional Testing: Specialty labs will do PCR for B. henselae from paraffin sections. Their number is 800-421-7110, Pacific Time, if you have specific questions. The samples would be sent through Molecular Diagnostics, as for TB.

CYTOGENETICS: 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)

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 · other

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University of Pittsburgh Medical Center

Molecular Diagnostics Division

MOLECULAR ONCOLOGY TESTS

Laboratory Mailing Address: Univ. of Pittsburgh Dept. of Pathology Division of Molecular Diagnostics Room S780 Scaife Hall 3550 Terrace Street Pittsburgh, PA 15213-2500 FAX: (412) 383-9594

IMPRINT PATIENT IDENTIFICATION PLATE HERE

Division Office: (412) 648-8519 Instructions: 1. 2. 3.

Complete all information as requested. Type or print clearly. Send lab copy of requisition with specimen. Specimens can be received Monday through Friday; see Specimen requirements for weekend storage conditions.

Specimen Type and Requirements:

Peripheral Blood: Bone Marrow: Tissue: 3 - 5 ml, collected in EDTA (purple top) tube, store at room temperature, 24 hours. 0.5 - 1ml, collected in an EDTA (purple-top) tube, store at room temperature, 24 hours. Frozen or fresh tissue may be used. A minimum of 2 x 2 x 2 mm is required (5 x 5 x 5 mm is preferred). For local facilities, we prefer the tissue to be sent fresh on wet ice to arrive in the lab on the same day. For outside facilities, the preferred approach is to snap freeze tissue directly or as cell pellets at -20 or -70°C and mail with sufficient dry ice to prevent thawing before arrival at our laboratory.

Please state tissue source:

Paraffin Sections: 10 sections on glass slides. More sections may be required if the tissue is small. Please call the lab if you have questions.

Sample Information Collection Date: Patient Identification: Name: Ordering Facility: Facility Address: Requesting Physician Name (Required): Physician Address: Name of Person Responsible for Payment: Billing Address: Insurance Information:

Collection Time: SS#: Sex: M F

ICD-9 code (required): Birth date: ) ) ) ) )

Phone#: ( FAX#: ( Phone#: ( FAX# ( Phone# (

Clinical history:

Please "X" Appropriate Test Request(s): and Storage

DNA and/or RNA Isolation t(11q23;others), MLL;others, Southern blot t(14;18), BCL2-IGH translocation studies (all studies will be performed unless individually checked) BCL2-IGH, Major breakpoint region (Mbr), PCR BCL2-IGH, Minor cluster region (mcr), PCR BCL2-IGH, Mbr and mcr, Southern blot t(15;17), PML-RARA translocation, RT-PCR T-cell receptor gene rearrangement studies Gamma chain (PCR) Beta chain (Southern blot) Other (Please state test requested):

Molecular Diagnostic consultation ­ will order appropriate studies after reviewing histopathologic and other information. Nucleic acid will be stored for potential future testing if molecular testing is not indicated. EBV Clonality Study (Terminal Repeat Analysis), Southern Blot Immunoglobulin heavy chain gene rearrangement studies PCR Southern Blot t(3;others), BCL6;others, Southern blot t(8;others), c-MYC;others, Southern blot t(9;22), BCR-ABL m-BCR, qualitative RT-PCR (some ALL cases) t(9;22), BCR-ABL M-BCR, qualitative RT-PCR (CML, some ALL) t(9;22), BCR-ABL, quantitative RT-PCR (available Spring 2004)

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PITTSBURGH CYTOGENETICS LABORATORY

at Magee-Womens Hospital

300 Halket Street, Rm. 1225 Pittsburgh, PA 15213-3160 TEL:(412)641-5558 FAX: (412)641-8730 PATIENT INFORMATION (Please Print): Last Name: First: Address: City, State, Zip: Birthdate: ___________________ Sex: ______ Male ______ Female Social Security #: ___________________ Medical Record #: Account#: Inpatient? _____ Location: _______________ Outpatient? _____ Send Bill To: ____ Insurance ____ Patient ____ Institution(list): _______________________________________ Insurance Information: Guarantor: ______________________________________________ Policy #: ____________________ Group #: ___________________ Insurance Co./Address: SPECIMEN INFORMATION: Date/Time of Collection: ________________________ Amount Drawn: _________ 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%. Signature of Requesting Physician (REQUIRED!): INDICATION FOR STUDY: (MUST BE COMPLETED!) Anemia _____ Thrombocytopenia _____ Leukocytosis _____ Leukopenia _____ Pancytopenia _____ Lymphoma _____ Diagnosis: Tentative ____ Confirmed ____ New Diagnosis? ____ Remission Sample? ____ Relapse Sample? ____ CML ____ ANLL ____ ALL ____ Chronic Phase ____ AML (FAB type M1,M2) ____ FAB type L1 ____ MDS ____ P. vera ____ Blast Phase _____ APL (FAB type M3) ____ FAB type L2 ____ CLL ____ Mult. Myeloma ____ AMMol (FAB type M4) ____ FAB type L3 ____ Other _____________________ Myeloproliferative Disorder? (Specify): ____________________________________________________________________ Other (Specify): _______________________________________________________________________________________ TEST(S) REQUESTED: (MUST BE COMPLETED!) _____ Chromosome Analysis (Karyotype) ____ Fluorescence in-situ hybridization(FISH): ____ t(11;14) (IGH/CCND1) ____ t(14;18) (IGH/BCL2) _____ t(9;22) (BCR/ABL) ____ R/O Trisomy 8 _____ t(8;21) (AML1/ETO) _____ t(8;14) (IGH/MYC) _____ t(15;17) (PML/RARA) ____ t(12;21) (TEL/AML1) _____ R/O del(13q) _____ inv(16) (CBFB) _____ R/O Monosomy 7 ____ R/O deletion 5q _____ X/Y (sex-mismatched BMT) _____ 11q23 _____ Other (specify): _________________________________

Oncreq.doc 7/02 SJK

ONCOLOGY Cytogenetics Request

Lab Accession #: Date Received:

M.I.: REFERRING PHYSICIAN (Please Print): Name: Address: City, State, Zip: Telephone:

Tech.: ___

Fax:

Additional Report To:

Address: City, State, Zip: Phone: Fax:

Pre-Bone Marrow Transplant ____ Post-Bone Marrow Transplant ____ #days _____ Sex of Donor : Male _____ Female ______ Clinical History/Pertinent Physical Findings (include chemotheraphy and radiation therapy dates/drugs):

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CoPath and Dictation Pointers

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COPATH Related Instructions for Dictation of Final Reports 1. At time of dictating any report, the patient name, surgical 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 signout queue. During this process the trainee is to verify that the final diagnosis matches that written on the hard copy during signout. 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 must have 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

BC#

1 2 3 6 14 15

Consultation Type

Level I Consult Level II Consult Level III Consult Lymph Nodes with Flow Cytometry and No Immunostains No Charge Stains, only

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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 preceed 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.

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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. · Abbreviations should be avoided. · 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. Comment: · Pending the department preparing the synoptics that were submitted in 2001, 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. · The comment should stress the major diagnosis first and must be consistent with the diagnoses listed above (eg, 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 (eg, 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.

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·

On "UP" consult cases, be sure to dictate a billing code at the end. Cases with flow plus just H&E sections get BC6. Most of our other UP cases get BC3.

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 (eg, 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 templated tables don't have capital letters in the middle of a sentence. · 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. *Much of this pertains to bone marrow reports as well; however, the mechanics by which they come with histories generally dictated are not reviewed here.

November 6, 2004

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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". 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. Log into CoPath. From the top menu bar, choose FILE. Choose BROWSE ITEMS. Look in the Browse Items menu list. Scroll down until you get to HEME WORKSHEET. 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 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 Log into CoPath. From the top menu bar, choose FILE. Choose BROWSE ITEMS. 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. 1. 2. 3. 4.

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Web-Based Resources

Note: Additional non-web based resources are in PUH C601.

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WEBSITE EDUCATIONAL RESOURCES & CALL SCHEDULES

Division of Hematopathology Intranet website (Hematopathology schedules/paging and general information) 1. http://aplis.upmc.edu/upmcintranet/outreach/PathDivs/HemPath.html For call schedule 1. http://residents.pathology.pitt.edu/Lists/Call%20Schedule/Upcoming%20Events2.htm UPMC Pathology Residents Server (includes on call schedule for AP and CP) 1. http://residents.pathology.pitt.edu/ Taking optimal pictures in Pics Plus 1. http://aplis.upmc.edu/ Hematological Malignancies Program http://www.upci.upmc.edu/hemmalig/ For general pathology (Hematopathology, Dermatopathology and others) 1. http://www-medlib.med.utah.edu/WebPath/webpath.html 2. http://www.vh.org/Providers/TeachingFiles/MultimediaTeachingFiles.html (This site includes teaching files and images from the Department of Pathology, University of Iowa College and Medicine) 3. http://www.tumorboard.com/ (contains a very large collection of copyright-free pathology images) 4. http://dermatlas.med.jhmi.edu/derm (Users can search by categories, diagnoses, or body site) For CD information (e.g., reactivity, etc): 1. http://www.ncbi.nlm.nih.gov/prow/

Hematology

Tutorials 1. 2. 3. 4. http://www.uu.edu/class/jmcgh/index.htm http://www.aum.iawf.unibe.ch/vlz/bwl/HemoSurf/IndexE.htm http://meds-ss10.meds.queensu.ca/medicine/deptmed/hemonc/anemia/handout.htm http://medic.med.uth.tmc.edu/path/00000286.htm

Atlas 1. http://image.bloodline.net/category 2. http://www.ashimagebank.org/ (ASH image bank)

Virtual Slide Gallery 1. http://interscope.hillman.upmc.edu/simpleviewer/ (See list of currently available cases following the website list) 2. http://cclcm.ccf.org/vm/VM_cases/lymphoid_main.htm

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(Virtual hematopathology slides (and other fixed images) from Cleveland Clinic)

General 1. www.dartmouth.edu/~nlevy/wwwx.html 2. http://image.bloodline.net/category 3. http://medmark.org/hem/ 4. http://www.mic.ki.se/Diseases/c15.html 5. http://edcenter.med.cornell.edu/Courseware/Pathology_Image_Collection.html (Weill Medical College of Cornell University : Hematopathology) 6. http://www.nci.nih.gov/ (treatment of leukemias/lymphoma) Case Studies 1. http://www.bloodline.net/case/index 2. http://www.uchsc.edu/sm/pmb/medrounds/hemeindex.html 3. http://path.upmc.edu/cases.html 4. http://research.med.umkc.edu/teams/blue2/q3.html 5. http://www1.umn.edu/hema/pages/casestudies.html 6. http://www.uu.edu/class/jmcgh/casestud/index.htm 7. http://www.geocities.com/HotSprings/2255/blood.html 8. http://medocs.ucdavis.edu/IMD/420A/course.htm 9. http://www.ec.hscsyr.edu/path/hemepath/cvframe.htm Society for Hematopathology Case of the Quarter 1. http://researchpath.hitchcock.org/SocForHeme/caseQuarter.html

USCAP Hematopathology Evening Session Cases 1. http://www.uscap.org/ Quiz Pages 1. http://courses.nus.edu.sg/Course/patleesh/morph1/slides.htm

Societies

1. 2. 3. 4. 5. 6. 7. 8. 9. http://www.hematology.org/ http://home.istar.ca/~chcts/ http://www.aspho.org/ http://www.blacksci.co.uk/uk/society/bsh/default.htm http://www.dartmouth.edu/~nlevy/EAHP/eahp.html http://www.ato.org.tr/konuk/thd/ http://www.leukemia.org/ http://www.dartmouth.edu/~nlevy/wwwx.html http://www.wfh.org/

CD Antigen Information

1. http://mpr.nci.nih.gov/prow/

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Flow Cytometry

Flow cytometry Case Journal 1. www.flowcases.org Educational Site 1. http://medic.uth.tmc.edu/edprog/00000014.htm 2. http://www.cyto.purdue.edu/index.htm 3. http://flowcyt.cyto.purdue.edu/flowcyt/educate/pptslide.htm 4. http://www.cyto.purdue.edu/flowcyt/educate/pptslide.htm 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/flowcyt/books/refclin.htm

Cytogenetics 1. www.infobiogen.fr/services/chromcancer/index.html (Atlas of Genetics and Cytogenetics in Oncology and Hematology) 2. http://www.pathology.washington.edu/Cytogallery/

NOTE: IF THERE ARE ANY SITES YOU FEEL SHOULD BE ADDED TO THIS LIST OR DEFUNCT SITES, PLEASE LET DR. SWERDLOW KNOW

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Virtual Gallery ­ Lymph Nodes

069 070 071 072 073 074 075 076 077 078 079 080 081 082 083 084 085 086 087 088 089 090 091 092 093 094 095 096 097 098 Reactive lymph node w/progressive transformation of germinal centers Lymphocyte-depleted Hodgkin's disease B-cell lymphoid neoplasm, strongly favor prolymphocytic transformation of SLL/CLL Nodular sclerosing Hodgkin's disease, syncytial-type Malignant lymphoma, follicular center cell type, large non-cleaved, diffuse (diffuse large B-cell lymphoma) Histiocytic necrotizing lymphadenitis (Kikiguchi-Fukimoto disease) Angiofollicular hyperplasia (Castleman's disease) Nodular sclerosing Hodgkin's disease HIV reactive lymphadenopathy Reactive hyperplasia w/features suggestive of toxoplasmosis Reactive lymph node w/features of Castleman's disease Malignant lymphoma, interfollicular SLL/CLL Malignant lymphoma, follicular center cell type, large non-cleaved cell predominant w/ immunoblastic features Malignant lymphoma, follicular center cell type, large non-cleaved cell predominant, nodular & diffuse Malignant lymphoma, SLL/B-CLL w/prominent proliferation centers & plasmacytoid features Malignant lymphoma, lymphoplasmacytic subtype (plasmacytoid lymphoma) Malignant lymphoma, follicular center cell type, small cleaved cell predominant, nodular Malignant lymphoma, follicular center cell type, small cleaved cell predominant, nodular & diffuse w/ sclerosis Interfollicular Hodgkin's disease Sarcoidosis Kimura's disease Interfollicular Hodgkin's disease Reactive hyperplasia w/dermatopathic change & vascular transformation of the sinuses Lymphocyte-predominant Hodgkin's disease Mixed cellularity Hodgkin's disease "Extranodal" Rosai-Dorfman disease (sinus histiocytosis w/ massive lymphadenopathy) B-MALT, thyroid gland Malignant lymphoma, mantle cell type (this case was CD5- by both flow cytometry & immunohistochemistry, Cyclin D1 was +) Dermatopathic lymphadenopathy Dermatopathic lymphadenopathy w/involvement by cutaneous T-cell lymphoma (mycosis Fungoides / Sézary syndrome)

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Conference Access for Pathology Faculty and Residents

Visit Department of Pathology Home Page, http://path.upmc.edu Click on "Online Conference" on the Yellow BULLETIN section (right hand side) Weekly Conference include: Current Topics in Laboratory Medicine Departmental Seminar Clinical Pathology Didactic Lecture Diagnostic Pathology conference Anatomic Pathology Didactic Lecture Series View them all LIVE on Mondays, Wednesdays, Thursdays and Fridays at Noon, and Thursdays at 8am, View them archived (since February 2002) anytime of the day. These LIVE and archived conferences are only accessible through the UPMC network. Please make sure you meet the requirements below: Soundcard and Speakers on your PC Volume adjusted RealPlayer 8 Basic (free). Please call Ahmed (412-647-9552) to have it installed on your PC If you don't have it already.

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Information

Flow Cytometry Worksheet

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