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QUALITY IMPROVEMENT IN DIAGNOSTIC HEMATOPATHOLOGY: AN INTEGRATION OF HUMAN RESOURCES AND OF ADVANCING TECHNOLOGIES

QUALITY IMPROVEMENT IN DIAGNOSTIC HEMATOPATHOLOGY: AN INTEGRATION OF HUMAN RESOURCES AND OF ADVANCING TECHNOLOGIES. M. MARINO. Dept . of Pathology REGINA ELENA NATIONAL CANCER INSTITUTE Rome , Italy. Management in Anatomia Patologica: Quale rischio? Rome , October 22-24, 2009.

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QUALITY IMPROVEMENT IN DIAGNOSTIC HEMATOPATHOLOGY: AN INTEGRATION OF HUMAN RESOURCES AND OF ADVANCING TECHNOLOGIES

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  1. QUALITY IMPROVEMENT IN DIAGNOSTIC HEMATOPATHOLOGY: AN INTEGRATION OF HUMAN RESOURCES AND OF ADVANCING TECHNOLOGIES M. MARINO Dept. ofPathology REGINA ELENA NATIONAL CANCER INSTITUTE Rome, Italy Management in Anatomia Patologica: Quale rischio? Rome, October 22-24, 2009

  2. Hematopathologyisconsidered a subspecialityofPathologyrequiring routine useofancillarytechniquessuchasimmunohistochemistry in orderto set a diagnosticupdatedevaluationoflymphoproliferative and myeloproliferativedisorders Molecularbiologicalmethods and viral status are actuallyrequired in some cases in ordertoreach a diagnosis

  3. The WHO classificationboth in 2001 and with the 2008 update clearlydefiniedlymphomaentitiesbasing on morphological, immunophenotypical, genetical and clinical data

  4. OUR CASES IN THE YEARS 2001-2009, ABOUT 600 FIRST LYMPHOMA DIAGNOSES OR SECOND OPINION EVALUATION HAVE BEEN DONE CHRONIC LYMPHOPROLIFERATIVE DISORDERS AND MULTIPLE MYELOMA CASES ARE ALSO FREQUENTLY DIAGNOSED MOST OF THE PATIENTS ARE FOLLOWED AT THE INSTITUTE, THUS ALLOWING AN EVALUATION OF THE DISEASE OVER THE YEARS

  5. Disease Management Team (DMT) meetingsas a quality procedure Experience at the Regina Elena National CancerInstitute, Rome Multidisciplinary team (pathologist / hematologists/ radiologist / radiotherapist / Cytofluorimetryspecialist / Cytogenetistaspermanentcomponents) Psychologist / neurologist / surgeons / dermatologists / nuclear medicine Weeklymeetings Discussionofeverynew case and duringfollow up Therapeuticaldecisions

  6. In Clinical Pathology, extensive characterization of lymphoid populations was obtained by flowcytometry analysis In Clinical Pathology Fluorescent In Situ Hybridization (FISH) cytogenetic analysis of bone marrow and, in the Pathology Department, of formalin-fixed, paraffin embedded tissue was established for the major chromosomal aberrations in lymphoma. Clonality studies in lymphoma diagnosis for both B- and T-cell proliferation have been established in the Pathology Dept.by capillary electrophoresis analysis of PCR products by using the BIOMED-2 protocol

  7. QUALITY CONTROL IN HEMATOPATHOLOGY • Secondinterinstitutionalreview • Secondpathologyreview • 3)Continuousmedicaleducation

  8. SECOND REVIEW • Interinstitutionalsecondreviewis a spontaneous and traditionalmethodtoverify and validate hematopathologicaldiagnoses • The secondreviewderives: • From a spontaneouschoiseof the pathologistdealingwithdifficult or controversialcases (forexample, discordantdiagnosiswith a previouspathologist) • From the clinical’s requestof a second opinion in a national/internationalreference center • 3) From the patientrequest

  9. Cases Amongabout 600 newlymphomadiagnoses in the years 2001-2009, 45 cases (about 7.5%) havebeenreview in the Reference center listed Some fewcasesdirectly sent from the patientcouldbemissingtothisreviewifnotlaterreportedto the clinicians or to the pathologist

  10. Referencecentersinvolved • HematopathologyUnit, Policlinico S. Orsola, Bologna (Prof. S. Pileri) • 2) Dept. OfPathology, UniversityofWuerzburg, Germany (Prof. HK Mueller-Hermelink • 3) Centro Oncologico di Aviano (Dr Canzonieri) • 4) S. Giovanni Rotondo, Casa Sollievo della Sofferenza (Dr M. Bisceglie)

  11. 33 cases out of 45 received the samediagnosis • 1) DLBL 7 cases • 2) ALCL 1 case • 3) MZL 5 cases • 4) FL 3 cases • 5) BL 1 case • 6) AILD 2 cases • 7) NK 1 case • 7) T-Lb 1 case • 8) FDCS 1 case • 9) HL 6 cases • 10) Inflammatory 3 cases • 11) Negative forlymph. 1 case • 12) Insufficient material 1 case

  12. A discordantdiagnosiswasreceived in 10 cases • Problemanalysis • 1) Overevaluationofnormalnodularmucosal pattern / no molecular data 1 • Underevaluationofnodular pattern/no sufficientimmunohistochemicalstudy 1 • OverevaluationofmonotonousFollicles / molecular data pointedto the correctdiagnosis 1 • 4) Misinterpretationoflargeatypicalcells 1 • 5) Suspicious PTCL vs T cell area hyperplasia/ T celllymphoma vs blastoidphaseKikuchilymphadenitis(1 case withoutmolecular data, 1 with) 2 • 6) PTCL underevaluatedasnecrotizinglymphadenitis 1 • 7) PCNS B-Lb vs BL; T-Lb vs AILD (misinterpretationofTdtresults) 2 • 8) Underevaluationof a focalinvolvementby HL 1

  13. 2 ADDITIONAL CASES OF EXCEPTIONAL DIAGNOSTIC DIFFICULTY HAVE ALSO BEEN SENT, AND EVALUATED ONLY AT THE REFERENCE CENTER

  14. Appropriate useofancillary and molecularbiologicalmethodsrequireexperience and knowledgeoflimitsofeachtechnique

  15. S. Conti , R. Covello, F. Marandino, S. Sioletic, S. Buglioni, G. Chichierchia, R. Martucci, P. Canalini, A. Papadantonakis, E. Gallo, B. Antoniani R. PerroneDonnorso Dept. OfPathology F. Pisani, L. Dessanti, M. D’Andrea, M.C. Petti Hematology R.Merola, I. Cordone ClinicalPathology

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