ANP.08216, Formaldehyde/Xylene Safety
“Formaldehyde and xylene vapor concentrations are maintained below the following maxima, expressed as parts per million, in all areas of the Anatomic Pathology Department where formaldehyde or xylene are used., NOTE: Formaldehyde and xylene vapor concentrations must be monitored in all areas where these reagents are used: e.g. surgical pathology gross dissection room, frozen section area, histology laboratory, autopsy room, etc. Xylene vapor concentration monitoring in histology laboratories should include manual and automated coverslipping areas, as these locations are often not ventilated. Initial monitoring involves identifying all employees who may be exposed at or above the action level or at or above the STEL and accurately determining the exposure of each employee identified. Further formaldehyde monitoring is mandated at least every 6 months if results of the initial monitoring equal or exceed 0.5 ppm (8 hr time-weighted exposure, the “action level”) or at least once per year if the results exceed the short term exposure limit (STEL) 2.0 ppm. The laboratory may discontinue periodic formaldehyde monitoring if results from 2 consecutive sampling periods taken at least 7 days apart show that employee exposure is below the action level and the short-term exposure limit, and 1) no change has occurred in production, equipment, process or personnel or control measures that may result in new or additional exposure to formaldehyde, and 2) there have been no reports of conditions that may be associated with formaldehyde exposure.
Formaldehyde monitoring must be repeated any time there is a change in production, equipment, process, personnel, or control measures which may result in new or additional exposure to formaldehyde for any employee involved in the activity. If any personnel report signs or symptoms of respiratory or dermal conditions associated with formaldehyde exposure, the laboratory must promptly monitor the affected person’s exposure.
Xylene must be monitored initially, but there is no requirement for periodic monitoring of xylene. Repeat monitoring should be considered when there is a change in production, equipment, process, personnel, or control measures likely to increase exposure levels., “
ANP.10016, Surgical Pathology Exclusion
“There is a policy that lists specimens that an institution may choose to exclude from routine submission to the pathology department for examination. , NOTE: This policy should be made in conjunction with the hospital administration and appropriate medical staff departments. The laboratory director should have participated in or been consulted by the medical staff in deciding which surgical specimens are to be sent to the pathology department for examination.
This checklist item is not applicable if 1) all specimens are submitted to pathology, or 2) the laboratory is not part of an institution that provides surgical services., “
ANP.10032, Surgical Pathology Microscopic Exemptions
There is a policy regarding what types of surgical specimens (if any) may be exempt from microscopic examination., NOTE: Irrespective of any exemptions, microscopic examination should be performed whenever there is a request by the attending physician, or at the discretion of the pathologist when indicated by the clinical history or gross findings. If there is such a policy, it should be approved by the medical staff or appropriate committee. Typical exempt specimens include foreskins in children, prosthetic cardiac valves without attached tissue, torn meniscus, varicose veins, tonsils in children below a certain age, etc.,
ANP.10050, Previous/Current Material Review
Whenever appropriate, pertinent previous cytologic and/or histologic material from the patient is reviewed with current material being examined., NOTE: Because sequential analysis of cytologic and histologic specimens may be critical in patient management and follow-up, efforts must be made to routinely review pertinent previous material. Documentation of the retrospective review should be included in the current patient report.,
ANP.10100, Intra-operative/Final Diagnosis Disparity
When significant disparity exists between initial intra-operative consultation (e.g. frozen section, intra-operative cytology, gross evaluation) and final pathology diagnosis, it is reconciled and documented in the surgical pathology report and in the departmental quality management file., ,
ANP.10150, Intra and Extra-Departmental Consultations
“The laboratory has a policy for handling intra- and extra-departmental consultations in the patient’s final report., NOTE: Intra-departmental consultations may be included in the patient’s final report, or filed separately. The pathologist in charge of the surgical pathology case must decide whether the results of intra-departmental consultations provide relevant information for inclusion in some manner in the patient’s report.
Documentation of extra-departmental consultations must be readily accessible within the pathology department. The method used to satisfy this requirement is at the discretion of the laboratory director, and can be expected to vary according to the organization of the department. These consultations can be maintained with the official surgical pathology reports or kept separately, so long as they can be readily linked., “
ANP.10250, Extra-Departmental Consultation
When extra-departmental cases are submitted to the laboratory for consultation, they are accessioned according to the standard practices of the laboratory, and a documented report is prepared, with a copy sent to the originating laboratory., NOTE: In most cases, original materials including slides and blocks should be promptly returned to the original institution. However, in some situations (for example, when the patient is receiving ongoing care at the referral institution pending tumor resection, etc.) it may be appropriate for the referral laboratory to retain slides/blocks for a period of time. In such situations, a letter should be sent to the originating laboratory along with the consultation report, requesting permission to retain the slides/blocks and accepting transfer of stewardship of the patient materials from the original laboratory to the referral institution.,
ANP.10255, Professional Competency
The laboratory director ensures the professional competency of pathologists who provide interpretive services to the anatomic pathology laboratory., NOTE: The mechanism for competency assessment must be pertinent to the type of interpretive services provided. There must be a written policy for assessing professional competency, criteria for the assessment, and records of the assessment must demonstrate review by the laboratory director.,
ANP.10260, Slide/Block Handling
There is a policy defining the handling of original slides/blocks for consultation and legal proceedings., NOTE: This must include appropriate handling and documentation of the use, circulation, referral, transfer, and receipt of original slides and blocks. The laboratory must have a record of the location of original slides and blocks that have been referred for consultation or legal proceedings.,
ANP.10270, Off-Site Autopsies
As applicable, there is a policy for performance of autopsies off-site., NOTE: If feasible, the autopsy room should be located within the institution. Requirements in the Autopsy Pathology section that relate to the physical facility, dissection and handling of organs and tissues apply only to those cases that are performed at the site under CAP accreditation. The pathologist should encourage off-site locations where autopsies are performed (e.g. Funeral homes) to provide facilities that meet the standards expected for accredited autopsy rooms.,
ANP.11250, Adequate Storage
Refrigerated storage is available for large or unfixed specimens., ,
ANP.11275, Radioactive Material Handling
“There are specific policies and procedures for the safe handling of tissues that may contain radioactive material (e.g. sentinel lymph nodes, breast biopsies, prostate ““seeds,”” etc.)., NOTE: These procedures should be developed in conjunction with the institutional radiation safety officer, and must comply with any state regulations for the safe handling of tissues containing radionuclides. The policy should distinguish between low radioactivity specimens such as sentinel lymphadenectomy and implant devices with higher radiation levels.
The pathology department may wish to monitor these specimens for radioactivity, with safe storage of specimens until sufficient decaying has occurred, before proceeding with processing in the histology laboratory. , “
ANP.11475, Sub-Optimal Specimens
There are documented procedures for handling sub-optimal specimens (e.g. specimens that are unlabeled, not labeled with two patient identifiers on the container, unaccompanied by adequate requisition information, left unfixed or unrefrigerated for an extended period, received in a container/bag with a contaminated outside surface)., ,
ANP.11500, Specimen Identity
The identity of every specimen is maintained at all times during the processing and examination steps., ,
ANP.11525, Tissue/Cytology Assessment Record
If a statement of adequacy, preliminary diagnosis, or recommendations for additional studies is provided at the time of tissue and cytology sample collection, documentation of that statement is maintained., NOTE: Documentation might include a note in the medical record or in the final report.,
ANP.11550, Specimen Retention
Gross specimens are retained until at least 2 weeks after the final reports are signed and results reported to the referring physician., ,
ANP.11600, Gross Examination - Pathologist
All macroscopic tissue gross examinations are performed by a pathologist or pathology resident, or under the supervision of a qualified pathologist., NOTE: Specific requirements for supervision of non-pathologists who assist in grossing specimens, are given below.,
ANP.11605, Gross Examination - Non-Pathologist
When individuals other than a pathologist or pathology resident assist in gross examinations, the extent of their activities and the nature of supervision (direct vs. indirect) is defined in a documented protocol., NOTE: This protocol must list the specific types of specimens for which non-pathologists are permitted to assist in the gross examination. The nature of the supervision must be established individually, for each non-pathologist. The laboratory director is responsible for this protocol. For Mohs surgery a dermatologist is also qualified to perform the gross examination and to supervise non-pathologists.,
ANP.11610, Gross Examination Qualifications
“If individuals other than a pathologist or pathology resident assist in gross examinations, such individuals qualify as high complexity testing personnel under CLIA regulations., NOTE: The laboratory director may delegate the dissection of specimens to non-pathologist individuals; these individuals must be qualified as high complexity testing personnel under CLIA regulations. The minimum training/experience required of such personnel is:
- An earned associate degree in a laboratory science or medical laboratory technology, obtained from an accredited institution, OR
- Education/training equivalent to the above that includes at least 60 semester hours or equivalent from an accredited institution. This education must include 24 semester hours of medical laboratory technology courses, OR 24 semester hours of science courses that includes 6 semester hours of chemistry, 6 semester hours of biology, and 12 semester hours of chemistry, biology or medical laboratory technology in any combination. In addition, the individual must have laboratory training including either completion of a clinical laboratory training program approved or accredited by the ABHES, NAACLA, or other organization approved by HHS (note that this training may be included in the 60 semester hours listed above), OR at least 3 months documented laboratory training in each specialty in which the individual performs high complexity testing.
It is the responsibility of the laboratory director to determine whether an individual’s education, training and experience satisfies the requirements of this checklist requirement.
This checklist requirement applies only to laboratories subject to US regulations., “
ANP.11640, Competency Assessment of Non-Pathologists
“The competency of non-pathologist(s) who assist in the performance of gross tissue examinations is assessed by the pathologist at least annually., NOTE: Please refer to GEN.55500, Competency Assessment, in the Laboratory General checklist for a list of criteria and frequency for competency assessment. Not all six elements may apply in all cases.
For Mohs surgery a dermatologist is also qualified to perform the gross examination and evaluate non-pathologists., “
ANP.11650, Mohs Diagnosis
Mohs surgically excised tissue diagnoses are made by a dermatologist, dermatopathologist, or pathologist., NOTE: The diagnosis includes whether or not tumor is present, assessment of the margins, etc.,
ANP.11660, Pathologist Diagnosis
All surgical tissue diagnoses are made by a pathologist., ,
ANP.11670, Specimen - Gross Examination
Documented instructions or guidelines are readily available in the laboratory for the proper dissection, description, and histologic sampling of various specimen types (e.g. mastectomy, colectomy, hysterectomy, renal biopsy, etc.)., NOTE: The guidelines should address large or complicated specimen types and smaller specimens requiring special handling, such as muscle biopsies, renal biopsies, and rectal suction biopsies for Hirschsprung’s disease. Guidelines serve an important educational function in departments with postgraduate (residency) programs. However, they also are useful in providing consistency in the handling of similar specimen types in departments without such training programs.,
ANP.11713, Histologic Prep Quality
“There is documented evidence of daily review of the technical quality of histologic preparations by the pathologist or designee., NOTE: If specimens are referred to an outside laboratory for histologic processing, there must be a procedure for providing feedback on slide quality to the outside laboratory.
This checklist requirement is intended to apply to routine histology slides. Specific quality control requirements for special stains, immunohistochemistry, and other special studies are found elsewhere in this checklist., “
ANP.11716, Paraffin Microtomy
There is a written procedure that indicates the sectioning thickness of paraffin embedded tissue for various tissue types and procedures., NOTE: Paraffin embedded sections are routinely sectioned at 4-5 microns. Some tissues (e.g. renal biopsy) may require thinner sections, while some special stain techniques (e.g. congo red stain) may require thicker sections. Use of the recommendations in the table below is at the discretion of the laboratory director.,
ANP.11734, Slide Quality
Slides are of sufficient quality for diagnosis., NOTE: Histopathology slides must be of adequate technical quality to be diagnostically useful. Criteria to evaluate include adequate tissue fixation, processing, thickness of sections, absence of interfering tissue folds and tears, and good staining technique and cover slipping. For hematoxylin and eosin and other routine stains, the patient slide serves as the internal control to ensure adequate staining technique. The sections must be cut from sufficient depth in the block to include the entire tissue plane.,
ANP.11756, Reagents
All solutions and stains are properly labeled and changed on a defined schedule., NOTE: All solutions and stains must be properly labeled with the contents, and, if applicable, date they are changed/filtered and expiration date. All solutions and stains should be changed or filtered following a defined process, determined by the usage of the reagents.,
ANP.11800, Intra-Operative Slide/Container Labeling
Each slide and container used to submit residual tissue for routine processing is labeled with two identifiers., NOTE: Acceptable patient identifiers include name, date of birth, medical record, and accession number.,
ANP.11810, Frozen Section Preparation Quality
Frozen section, touch and scrape preparations are adequate for intra-operative diagnosis., ,
ANP.11850, Intra-Operative Results
The results of intra-operative surgical consultations are documented and signed by the individual who made the diagnosis., NOTE: The intent of this requirement is for the laboratory to maintain a contemporaneous report of the consultation. This may be a handwritten, signed report or a computer-generated report with electronic signature. ,
ANP.11900, Verbal Reports
If verbal reports are given, the pathologist is able to speak directly with intra-operative medical/surgical personnel., ,
ANP.11950, Verbal Report/Patient ID
The patient’s identification is checked and confirmed before delivery of any verbal report., ,
The patient’s identification is checked and confirmed before delivery of any verbal report., ,
The patient’s identification is checked and confirmed before delivery of any verbal report., ,
ANP.12050, Frozen Section Slides
All frozen section, touch and scrape preparation slides are permanently stained, mounted, properly labeled, and retained with the rest of the slides from the case., ,
ANP.12075, Residual Frozen Tissue
“Following frozen section examination, the residual frozen tissue is routinely processed into paraffin, and a histologic section prepared and examined for comparison with the frozen section interpretation., NOTE: The laboratory must prepare a paraffin block and stained slide(s) from each frozen section block, and such paraffin blocks must be retained in accordance with CAP guideline for retention of surgical pathology blocks (ANP.12500).
Correlation of frozen section findings with a permanent section prepared from routinely fixed and processed residual frozen tissue is an important quality improvement mechanism. Evaluation of such permanent sections provides important feedback on the accuracy of frozen section diagnoses and improves recognition of specific frozen section morphologic alterations.
The only exceptions to this requirement are as follows: 1) Frozen tissue that must be submitted for specialized studies; 2) Mohs frozen sections. However, the CAP strongly recommends preparation of paraffin sections from frozen tissue used for Mohs frozen sections, for quality management purposes. CAP also recommends retention of the tissue used for Mohs frozen sections in accordance with CAP retention guidelines., “
ANP.12092, FNA Specimen Labeling
If the pathologist performs FNA procedures or if laboratory personnel participate in FNA procedures, two patient identifiers are placed on the prepared slides and any specimen container at the time of the procedure., NOTE: All specimens must be labeled at the time of collection to provide unique identification. Each prepared slide must be labeled separately and any specimen container with collected material (e.g. fluid from aspiration) must also be labeled.,
ANP.12094, Error Prevention Patient ID
If the pathologist performs FNA procedures, there is a documented procedure to assure proper identification of the patient, the site and the procedure. , ,
ANP.12096, FNA Cross Contamination
There is a procedure to prevent cross contamination of FNA specimens during processing and staining., NOTE: Methods to minimize this problem may include cytocentrifuge, filter and monolayer preparations. Smears made from highly cellular cases should be stained after the other cases, and the staining fluids must be changed or filtered between each of the highly cellular cases. One procedure to detect contamination is to insert a clean blank slide in each staining run and examine it for contaminating cells.,
ANP.12170, Report Review
All reports are reviewed and signed by the pathologist., NOTE: The inspector must review a broad sampling of surgical pathology reports issued since the previous on-site inspection, representing at least the most common types of specimens seen in the laboratory. When diagnostic reports are generated by computer or telecommunications equipment, the actual signature or initials of the pathologist may not appear on the report. It is nevertheless essential that the laboratory have a procedure that ensures and documents that the responsible pathologist has reviewed and approved the completed report before its release. In the occasional situation when the diagnosing pathologist is not available for timely review and approval of the completed report, the laboratory may have a policy and procedure for review and approval of that report by another pathologist. In that circumstance, the names and responsibilities of both the pathologist who made the diagnosis and the pathologist who performs final verification must appear on the report.,
ANP.12173, Mohs Report
There is a written report generated for each Mohs surgical procedure., NOTE: A written note, report, or diagram must be included in the patient’s medical record or operative report. The report should include required elements such as gross description, accession number, designation of relationship of blocks to the slides, and clear diagnosis on each specimen.,
ANP.12175, Significant/Unexpected Findings
“There is a policy regarding the communication, and documentation thereof, of significant and unexpected surgical pathology findings., NOTE: Certain surgical pathology diagnoses may be considered significant and unexpected. Such diagnoses may include: malignancy in an uncommon location or specimen type (e.g. hernia sac, intervertebral disk material, tonsil, etc.), or change of a frozen section diagnosis after review of permanent sections. There should be a reasonable effort to ensure that such diagnoses are received by the clinician, by means of telephone, pager or other system of notification. There must be documentation of the date of communication of these diagnoses.
The pathology department may designate certain surgical pathology diagnoses for prompt communication to the clinician. Such diagnoses may include, for example, neoplasms causing paralysis, or fat in an endometrial curettage. There must be documentation of the date of communication of such results.
Diagnoses to be defined as “significant and unexpected,” and those for prompt communication should be determined by the pathology department, in cooperation with local clinical medical staff.
Documentation of communication of these diagnoses may be included in the pathology report, or in other laboratory records.
This requirement takes the place of critical result notification in the All Common Checklist (COM.30000 and COM.30100)., “
ANP.12185, Amended Reports
Amendments to reports that would significantly affect patient care are reported promptly to the responsible clinician(s)., NOTE: Records of notification should include date, time, and person notified, and preferably appear in the amended report. Periodic evaluation of amended reports is commonly included as part of the quality management program.,
ANP.12200, Gross Description Reporting
“All surgical pathology reports include gross descriptions, information essential for diagnosis and patient care, and record-essential processing information., NOTES:
- Descriptions should include information regarding type, number, dimensions and/or weight of specimens, measurements and extent of gross lesions
- Processing information should include a summary of block/slide designations for special sections as appropriate (e.g. margins of resection, breast quadrants, lymph node levels, etc.)
- Annotated drawings and photographs are valuable tools for documenting gross findings, but are not adequate replacements for a text description, “
ANP.12350, Cancer Protocols
“All data elements required in applicable CAP Cancer Protocols are included in the surgical pathology report., NOTE:
- The use of these protocols is encouraged, but not required, providing that the data elements required by the protocols are present in the report.
- Data elements not applicable to the specimen need not be included in the report. (For example, if a mastectomy specimen does not include lymph nodes, no reference to lymph nodes is required.)
- This checklist requirement is not applicable to cancer reports for which no CAP Cancer Protocol applies (for example, incisional biopsy of the breast) nor to reports on specimens that do not contain cancer.
- Reports must include the required data elements from the current edition of the CAP Cancer Protocols. Laboratories may use the previous edition of the Protocols for up to 8 months after publication of the current edition.
This checklist requirement should be cited by the inspector only if there is a pattern of repeated failure to include all requirements in multiple reports., “
ANP.12385, Synoptic Reporting
“Data elements required by applicable CAP Cancer Protocols are reported using a synoptic format., NOTE:
1 All required cancer data from an applicable cancer protocol that are included in the report must be displayed using a format consisting of the required checklist item (required data element), followed by its answer (response), e.g. ““Tumor size 5.5 cm.”” Outline format without the paired required data element (RDE): response format is not considered synoptic.
2 Each diagnostic parameter pair (checklist RDE: response) is listed on a separate line or in a tabular format, to achieve visual separation. For example:
- Headers may be used to separate or group data elements
- Any line may be indented to visually group related data elements or indicate a subordinate relationship
- Text attributes (e.g. color, bold, font, size, capitalization/case, or animations) are optional
- Blank lines may be used to separate data elements and group related elements
Note: the following are allowed to be combined on the same line:
- Anatomic site or specimen, laterality and procedure
- Pathologic Staging Tumor Node Metastasis (pTNM) staging elements
- Negative margins, as long as all negative margins are specifically enumerated
- If multiple responses are permitted for the same data element, the responses may be listed on a single line.
- The synopsis can appear in the diagnosis section of the pathology report, at the end of the report or in a separate section, but all RDE and responses must be listed together in one location.
- Additional items (not required for the CAP checklist) may be included in the synopsis but all required RDE must be present.
- Narrative style comments are permitted in addition to, but are not as a substitute for, the synoptic reporting. It is not uncommon for narrative style comments to be used for clinical history, gross descriptions and microscopic descriptions., “
ANP.12400, Correlation of Results
There is a mechanism to correlate the results of specialized studies (e.g. immunohistochemistry, nucleic acid probes, cytogenetics, flow cytometry, electron microscopy) with the morphologic diagnosis., NOTE: It is not in the best interests of the patient to have potentially conflicting diagnoses or interpretations rendered by different sections of the laboratory. The pathologist should issue a report reconciling potentially conflicting data, when appropriate.,
ANP.12425, ASR Disclaimer
“If patient testing is performed using Class I analyte-specific reagents (ASRs) obtained or purchased from an outside vendor, the patient report includes the disclaimer required by federal regulations., NOTE: ASRs are antibodies, both polyclonal and monoclonal, specific receptor proteins, ligands, nucleic acid sequences, and similar reagents which, through specific binding or chemical reaction with substances in a specimen, are intended for use in a diagnostic application for identification and quantification of an individual chemical substance or ligand in biological specimens.
By definition, an ASR is the active ingredient of a laboratory-developed test system. ASRs may be obtained from outside vendors or synthesized in-house. ASRs from outside vendors are supplied individually. They are not bundled with other materials in kit form, and the accompanying product literature does not include any claims with respect to use or performance of the reagent.
Class I ASRs in use in the anatomic pathology laboratory include some antibodies for immunohistochemistry and nucleic acid probes for FISH and ISH.
Class I ASRs are not subject to preclearance by the US Food and Drug Administration or to special controls by FDA. Thus, if the laboratory performs patient testing using Class I ASRs obtained or purchased from an outside vendor, federal regulations require that the following disclaimer accompany the test result on the patient report:
"”This test was developed and its performance characteristics determined by (laboratory name). It has not been cleared or approved by the US Food and Drug Administration.””
The CAP recommends additional language, such as ““FDA does not require this test to go through premarket FDA review. 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 (CLIA) as qualified to perform high complexity clinical laboratory testing.””
The above disclaimer is not required when using reagents that are sold in kit form with other materials and/or an instrument, and/or with instructions for use, and/or when labeled by the manufacturer as Class I for in vitro diagnostic use (IVD), Class II IVD, or Class III IVD.
Most antibodies used in immunohistochemistry are labeled “for in vitro diagnostic use” and thus do NOT require the disclaimer.
The laboratory must establish or verify the performance characteristics of tests using Class I ASRs in accordance with the Method Performance Specifications section of the All Common Checklist.
The laboratory may put an ASR disclaimer on the pathology report for all immunostains, FISH and ISH studies collectively used in a particular case. Separately tracking each reagent used for a case and selectively applying the disclaimer to only the class I ASRs is unnecessary. , “
ANP.12500, Record Retention
“Surgical pathology records and materials are retained for an appropriate period., NOTE 1: Minimum requirements for surgical pathology, providing these are not less stringent than local, state and national regulations, are:
- Accession log records - 2 years
- Wet tissue (stock bottle) - 2 weeks after final report
- Paraffin blocks - 10 years (subject to Notes 2 and 3, below)
- Glass slides (including control slides) and reports - 10 years (slides must remain readable for this period)
- Surgical pathology reports - 10 years (see Notes 4 and 5, below)
- Fluorochrome-stained slides - at the discretion of the laboratory director
- Fine needle aspiration slides - 10 years
- Images of FISH studies - 10 years (see Note 6, below)
There must be a documented policy for protecting and preserving the integrity and retrieval of surgical pathology materials and records. The retention period should be extended, when appropriate, to provide documentation for adequate quality control and medical care.
NOTE 2: Regarding extra-institutional release of blocks for research purposes: Federal regulations require that a laboratory retain paraffin blocks for two years unless the tissue is blocked specifically for research and not used for patient diagnostic purposes.* The CAP Commission on Laboratory Accreditation (CLA) requires, however, that paraffin blocks used for patient diagnostic purposes must be kept for at least 10 years. Nevertheless, such blocks may be released for research purposes after the two-year regulatory requirement if all of the following criteria are met:
- For laboratories subject to US regulations, formal written authorization is obtained in accordance with the requirements of HIPAA if identifiable patient information is released.
- The laboratory retains sufficient blocks to support the diagnosis for the full 10-year period.
- Provision is made for retrieval by the laboratory of any blocks or material that remain after use in research, if the blocks or material are needed for diagnostic, legal, or other legitimate purposes.
- The laboratory meets other relevant requirements including but not limited to the requirements of the institution, the directives of any applicable institutional review board (IRB) or similar entity; and state and local laws and regulations.
NOTE 3: Given that patient survival rates are increasing and the continued emergence of treatment based on biomarker testing, which at times may be required on the original tissue, it is recommended that, whenever feasible, tissue block retention from patients with diagnosed malignancies be retained beyond the 10 year requirement.
NOTE 4: Pathology reports may be retained in either paper or electronic format. If retained in electronic format alone, however, the electronic reports must include a secure pathologist electronic signature. Images of paper reports–such as microfiche or PDF files–are acceptable.
NOTE 5: Reports of outside consultations performed on cases from the laboratory (whether or not such consultation was requested by the laboratory) must be retained for 10 years after the date on which the original report was issued.
NOTE 6: There is no retention requirement for images when the source slides remain readable for the required 10-year retention period. The 10-year retention requirement applies to images of slide preparations that are not readable for the 10-year period (e.g. FISH studies).
*The restriction on release of blocks does not prohibit release of blocks for purposes of treatment, diagnosis, prognosis, etc., for patients on research protocols as long as release is consistent with patient privacy regulations (e.g. HIPAA) and applicable state and local regulations; and there is IRB approval, as applicable., “
ANP.21050, Specimen Identity
“The identity of every specimen is maintained through each step of tissue processing and block and slide preparation., NOTE: An unambiguous system of specimen identification coupled with a legible, sequential cassette and slide labeling system that withstands reagents and stains are essential to fulfill this requirement.
Each block of tissue must be identified by the entire accession number assigned to the case and by any descriptive letter(s)/number(s) added by the prosector during the dissection. If additional blocks are prepared later, all lists and logs must reflect these additions. Identification number and letter(s)/numbers(s) must be affixed to all blocks in a manner that remains legible.
Each slide must be identified by the entire accession number and descriptive letters unique to the block from which it is cut. Other appropriate identifiers should be included as applicable (e.g. levels of sectioning). Automated prelabeling systems are acceptable. Regardless of whether the identifying information is on the slide or on a label, the information must be indelible, legible and able to withstand all stages of processing and conditions of storage., “
ANP.21350, Specimen Preparation Records
The histology laboratory maintains records of the number of blocks, slides, and stains prepared., NOTE: Laboratories must be capable of demonstrating volumes for any given period of time.,
ANP.21360, Automated Stainer
There is a schedule to change the solutions in automated stainers., NOTE: Solutions must be changed at intervals appropriate for the laboratory’s workload. Changing, filtering, or addition to solutions should be documented when performed.,
ANP.21382, Reagent Expiration Date
“All reagents are used within their indicated expiration dates., NOTE: The laboratory must assign an expiration date to any reagents that do not have a manufacturer-provided expiration date. The assigned expiration date should be based on known stability, frequency of use, storage conditions, and risk of contamination.
This checklist requirement applies to all reagents used in the laboratory (histochemical, immunohistochemical, and immunofluorescent reagents, and reagents used for molecular tests).
The acceptable performance of histochemical stains is determined by technical assessment on actual case material, use of suitable control sections, and as part of the pathologist’s diagnostic evaluation of a surgical pathology or autopsy pathology case.
An exception to the above is that some histochemical reagents used in the histology laboratory are not subject to outdating, so that assignment of expiration dates may have no meaning. The acceptable performance of such reagents should be confirmed at least annually by technical assessment, as described above. (If the manufacturer assigns an expiration date, it must be observed.)
For laboratories not subject to US regulations, expired reagents may be used only under the following circumstances: 1. The reagents are unique, rare or difficult to obtain; or 2. Delivery of new shipments of reagents is delayed through causes not under control of the laboratory. The laboratory must document verification of the performance of expired reagents in accordance with written laboratory policy. Laboratories subject to US regulations must not use expired reagents., “
ANP.21395, Special Stains/Studies
For special stains and studies using immunologic and FISH/ISH methods, results of controls are documented to be acceptable before reporting patient results., ,
ANP.21450, Special Stain Quality
All histochemical stains are of adequate quality, and daily controls are demonstrated on each day of use for the tissue components or organisms for which they were designed., NOTE: Positive tissue controls assess the performance of the special stain. Special stains are performed on sections of control tissue known to contain components specific to each special stain. Verification of tissue used as a positive control must be performed and documented before being used with clinical specimens.,
ANP.21850, QC - Immunofluorescence
For immunofluorescence microscopy, appropriate positive and negative controls are performed. , NOTE: Internal antigens serve as positive controls (e.g. IgA in tubular casts, IgG in protein droplets and C3 in blood vessels). When internal positive controls are absent, daily external positive controls are required. Non-reactive elements in the patient specimen may serve as a negative tissue control. A negative reagent control in which the patient tissue is processed in an identical manner to the test specimen, but with the primary antibody omitted, should be performed for each patient test specimen at the discretion of the laboratory director. ,
ANP.22300, Specimen Modification
If the laboratory performs immunohistochemical staining on specimens other than formalin-fixed, paraffin-embedded tissue, the written procedure describes appropriate modifications for other specimen types., NOTE: Such specimens include frozen sections, air-dried imprints, cytocentrifuge or other liquid-based preparations, decalcified tissue, and tissues fixed in alcohol blends or other fixatives.,
ANP.22500, Buffer pH
The pH of the buffers used in immunohistochemistry is routinely monitored., NOTE: pH must be tested when a new batch is prepared or received.,
ANP.22550, QC - Antibodies
“Positive tissue controls are used for each antibody., NOTE: Positive controls assess the performance of the primary antibody. They are performed on sections of tissue known to contain the target antigen, using the same epitope retrieval and immunostaining protocols as the patient tissue. Results of controls must be documented, either in internal laboratory records, or in the patient report. A statement in the report such as, “All controls show appropriate reactivity” is sufficient.
Ideally, the positive control tissue would be the same specimen type as the patient test specimen (e.g. small biopsy, large tissue section, cell block), and would be processed and fixed in the same manner (e.g. formalin-fixed, alcohol-fixed, decalcified) as the patient specimen. However, for most laboratories, it is not practical to maintain separate positive control samples to cover every possible combination of fixation, processing and specimen type. Thus, it is reasonable for a laboratory to maintain a bank of formalin-fixed tissue samples as its positive controls; these controls can be used for patient specimens that are of different type, or fixed/processed differently, providing that the laboratory can show that these patient specimens exhibit equivalent immunoreactivity. This can be accomplished by parallel testing a small panel of common markers to show that specimens of different type, or processed in a different way (e.g. alcohol-fixed cytology specimens, decalcified tissue) have equivalent immunoreactivity to routinely processed, formalin-fixed tissue.
A separate tissue section may be used as a positive control, but test sections often contain normal elements that express the antigen of interest (internal controls). Internal positive controls are acceptable for these antigens, but the laboratory manual must clearly state the manner in which internal positive controls are used.
A positive control section included on the same slide as the patient tissue is optimal practice because it helps identify failure to apply primary antibody or other critical reagent to the patient test slide; however, one separate positive control per staining run for each antibody in the run (batch control) may be sufficient provided that the control slide is closely scrutinized by a qualified reviewer.
Ideally, positive control tissues possess low levels of antigen expression, as is often seen in neoplasms. Exclusive use of normal tissues that have high levels of antigen expression may result in antibody titers of insufficient sensitivity, leading to false-negative results., “
ANP.22570, QC - Antibodies
“Appropriate negative controls are used., NOTE: Negative controls must assess the presence of nonspecific staining in patient tissue as well as the specificity of each antibody with the exception listed below. Results of controls must be documented, either in internal laboratory records, or in the patient report. A statement in the report such as, ““All controls show appropriate reactivity”” is sufficient.
For laboratories using older biotin-based detection systems, it is important to use a negative reagent control to assess nonspecific or aberrant staining in patient tissue related to the antigen retrieval conditions and/or detection system used. A separate section of patient tissue is processed using the same reagent and epitope retrieval protocol as the patient test slide, except that the primary antibody is omitted, and replaced by any one of the following:
- An unrelated antibody of the same isotype as the primary antibody (for monoclonal primary antibodies)
- An unrelated antibody from the same animal species as the primary antibody (for polyclonal primary antibodies)
- The negative control reagent included in the staining kit
- The diluent/buffer solution in which the primary antibody is diluted
In general, a separate negative reagent control should be run for each block of patient tissue being immunostained; however, for cases in which there is simultaneous staining of multiple blocks from the same specimen with the same antibody (e.g. cytokeratin staining of multiple axillary sentinel lymph nodes), performing a single negative control on one of the blocks may be sufficient provided that all such blocks are fixed and processed identically. This exception does not apply to stains on different types of tissues or those using different antigen retrieval protocols or antibody detection systems. The laboratory director must determine which cases will have only one negative reagent control, and this must be specified in the department’s procedure manual.
The negative reagent control would ideally control for each reagent protocol and antibody retrieval condition; however, large antibody panels often employ multiple antigen retrieval procedures. In such cases, a reasonable minimum control would be to perform the negative reagent control using the most aggressive retrieval procedure in the particular antibody panel. Aggressiveness of antigen retrieval (in decreasing order) is as follows: pressure cooker; enzyme digestion; boiling; microwave; steamer; water bath. High pH retrieval should be considered more aggressive than comparable retrieval in citrate buffer at pH 6.0.
Immunohistochemical tests using polymer-based detection systems (biotin-free) are sufficiently free of background reactivity to obviate the need for a negative reagent control and such controls may be omitted at the discretion of the laboratory director following appropriate validation.
It is also important to assess the specificity of each antibody by a negative tissue control, which must show no staining of tissues known to lack the antigen. The negative tissue control is processed using the same fixation, epitope retrieval and immunostaining protocols as the patient tissue. Unexpected positive staining of such tissues indicates that the test has lost specificity, perhaps because of improper antibody concentration or excessive antigen retrieval. Intrinsic properties of the test tissue may also be the cause of ““non-specific”” staining. For example, tissues with high endogenous biotin activity such as liver or renal tubules may simulate positive staining when using a detection method based on biotin labeling.
A negative tissue control must be processed for each antibody in a given run. Any of the following can serve as a negative tissue control:
- Multitissue blocks. These can provide simultaneous positive and negative tissue controls, and are considered “best practice” (see below).
- The positive control slide or patient test slides, if these slides contain tissue elements that should not react with the antibody.
- A separate negative tissue control slide.
The type of negative tissue control used (i.e. separate sections, internal controls or multitissue blocks) must be specified in the laboratory manual.
Multitissue blocks may be considered best practice and can have a major role in maintaining quality. When used as a combined positive and negative tissue control as mentioned above, they can serve as a permanent record documenting the sensitivity and specificity of every stain, particularly when mounted on the same slide as the patient tissue. When the components are chosen appropriately, multitissue blocks may be used for many different primary antibodies, decreasing the number of different control blocks needed by the laboratory. Multitissue blocks are also ideal for determining optimal titers of primary antibodies since they allow simultaneous evaluation of many different pieces of tissue. Finally, they are a useful and efficient means to screen new antibodies for sensitivity and specificity or new lots of antibody for consistency, which should be done before putting any antibody into diagnostic use., “
ANP.22615, Endogenous Biotin
“If the laboratory uses an avidin-biotin complex (ABC) detection system (or a related system such as streptavidin-biotin or neutravidin-biotin), there is a policy that addresses nonspecific false-positive staining from endogenous biotin., NOTE: Biotin is a coenzyme present in mitochondria, and cells that have abundant mitochondria such as hepatocytes, kidney tubules and many tumors (particularly carcinomas) are rich in endogenous biotin. Biotin-rich intranuclear inclusions are also seen in gestational endometrium and in some tumors that form morules. If steps are not included in the immunostaining method to block endogenous biotin before applying the ABC detection complex, nonspecific false-positive staining may occur, particularly when using heat-induced epitope retrieval (which markedly increases the detectability of endogenous biotin). This artifact is often exquisitely localized to tumor cells and may be easily misinterpreted as true immunoreactivity.
Blocking endogenous biotin involves incubating the slides with a solution of free avidin (which binds to endogenous biotin), followed by incubation with a biotin solution (which saturates any empty biotin-binding sites remaining on the avidin). Biotin-blocking steps should be performed immediately after epitope retrieval and before incubation with primary antibody., “
ANP.22660, Control Slide Review
“When batch controls are run, the laboratory director or designee reviews all control slides each day of patient testing., NOTE: Records of this daily review must be maintained and should clearly document that positive and negative controls for all antibodies stain appropriately. Batch control records must be retained for 2 years.
The batch control slides must be readily available to pathologists who are signing out cases. The location of the slides should be stated in the procedure manual., “
ANP.22750, Antibody Validation
“The laboratory has documented validation of new antibodies, including introduction of a new clone, prior to use in patient diagnosis., NOTE: The performance characteristics of each assay in the immunohistochemistry laboratory must be appropriately validated before being placed into clinical use. The initial goal is to establish the optimal antibody titration, detection system, and antigen retrieval protocol. Once optimized, a panel of tissues must be tested to determine the assay’s sensitivity and specificity. The scope of the validation is at the discretion of the laboratory director and will vary with the antibody. For a well-characterized antibody with a limited spectrum of antigenic targets, like chromogranin or prostate specific antigen, the validation can be limited. A panel of 10 positive and 10 negative neoplasms would be sufficient in this setting. For validation of predictive markers, consideration should be made for a larger validation set. For an antibody that is not well characterized and/or has a wide range of reported reactivity, a more extensive validation is necessary. The number of tissues tested should, in this circumstance, be large enough to determine whether the staining profile matches that previously described.
An exception to the above requirements is that studies may not be feasible for antigens that are only seen in rare tumors.
This checklist has additional validation requirements for HER2 and estrogen/progesterone receptor testing in breast carcinoma. Please refer to the subsection ““Predictive Markers,”” below., “
ANP.22760, New Reagent Lot Confirmation of Acceptability
The performance of new lots of antibody and detection system reagents is compared with old lots before or concurrently with being placed into service., NOTE: Parallel staining is required to control for variables such as disparity in the lots of detection reagents or instrument function. New lots of primary antibody and detection system reagents must be compared to the previous lot using an appropriate panel of control tissues. This comparison must be made on slides cut from the same control block.,
ANP.22780, IHC Assay Performance
“Laboratories confirm assay performance when conditions change that may affect performance., NOTE: Laboratories should confirm assay performance with at least 2 known positive and 2 known negative cases when an existing validated assay has changed in any of the following ways: antibody dilution, antibody vendor (same clone), or the incubation or retrieval times (same method).
Laboratories must confirm assay performance by testing a sufficient number of cases to ensure that assays consistently achieve expected results when any of the following have changed: fixative type, antigen retrieval method (e.g. change in pH, different buffer, different heat platform), antigen detection system, tissue processing or testing equipment, environmental conditions of testing (e.g. laboratory relocation), or laboratory water supply., “
ANP.22900, Slide Quality
The immunohistochemical stains produced are of acceptable technical quality., NOTE: The inspector must examine examples of the immunohistochemical preparations offered by the laboratory. A reasonable sample might include 5-10 diagnostic antibody panels.,
ANP.22956, FISH/ISH Probe Validation
There is documentation of validation of all probes, including commercially available ISH and FISH probes, and probes developed by the laboratory (including those using analyte-specific reagents). , ,
ANP.22963, FISH/ISH Scoring
There are documented procedures for scoring results, including the number of cells scored; quantitative and semi-quantitative analyses are scored according to these procedures as applicable. , ,
ANP.22964, FISH/ISH Controls
Control loci (internal or external) are used with and documented for each FISH analysis., NOTE: When normal chromosome targets are expected to be present within a sample, an internal control for that target should be used during each hybridization (i.e. a locus specific probe at a different site on the same chromosome and/or a normal locus on the abnormal homolog). If a probe is used that does not produce an internal control signal (e.g. a Y chromosome probe in a female), or in the case of translocation FISH another sample that is known to have the probe target should be run in parallel with the patient sample.,
ANP.22965, Retention - Images
Photographic or digitized images are retained for documentation of all FISH assays (at least one cell for assays with normal results, and at least two cells for assays with abnormal results). , NOTE: For assays where multiple chromosomal loci (>2) are targets in part of a single test, an image of at least one cell must be retained for documentation of each target. Images of at least two cells are required to document all abnormalities. Images of FISH assays must be retained for 10 years.,
ANP.22966, Morphologic Interpretation
For in situ hybridization studies, the morphologic interpretation and correlation of results are performed by a qualified pathologist as appropriate., ,
ANP.22967, Report - Interpretation
Appropriate interpretation of in situ hybridization results are provided in the report. , ,
ANP.22969, Report Elements
“For immunohistochemical and FISH/ISH tests that provide independent predictive information, the patient report includes information on specimen processing, the antibody clone/probe, and the scoring method used., NOTE: For immunohistochemical and FISH/ISH studies used to provide diagnostic predictive information independent of other histopathologic findings (e.g. hormone receptors in breast carcinoma, HER2, EGFR), the laboratory should include the following information in the patient report:
- The type of specimen fixation and processing (e.g. formalin-fixed paraffin-embedded sections, air-dried imprints, etc.).
- The antibody clone or probe and general form of detection system used (e.g. LSAB, polymer, proprietary kit, etc.; information on the vendor name or type of equipment used is not necessary)
- Criteria used to determine a positive vs. negative result, and/or scoring system (e.g. percent of stained cells, staining pattern, etc.), “
ANP.22970, Annual Result Comparison
“For immunohistochemical and FISH/ISH tests that provide independent predictive information, the laboratory at least annually compares its patient results with published benchmarks, and evaluates interobserver variability among the pathologists in the laboratory., NOTE: Individuals interpreting the assay must also have their concordance compared with each other and this concordance should also be at least 95%.
With specific reference to estrogen and progesterone receptor studies: in general, the overall proportion of ER-negative breast cancers (invasive and DCIS) should not exceed 30%. The average is somewhat lower in postmenopausal than premenopausal women (approximately 20% vs. 35%). The average is considerably lower in well-differentiated carcinomas (
ANP.22973, PT for HER2, ER, and PgR
“The laboratory is enrolled in the appropriate CAP Surveys, or other CAP-accepted proficiency testing (PT) program, for HER2, ER, and PgR testing in breast carcinoma., NOTE: HER2 PT is method specific, and laboratories performing HER2 testing by multiple methods must participate in PT for each method. Details are available on the CAP website www.cap.org. Satisfactory performance requires correct responses on at least 90% of graded challenges in each testing event (mailing).
If the laboratory interprets HER2 test results from immunohistochemical stains prepared at another facility, the laboratory must (1) enroll in an appropriate PT survey, (2) send PT materials to the staining facility for preparation, and (3) interpret the resulting stains using the same procedures that are used for patient specimens. If the laboratory interprets FISH (or ISH) stains for HER2 prepared at another facility, the laboratory must not participate in PT, but must perform an alternative assessment of the test twice annually. , “
ANP.22976, ER/PgR Validation
“If the laboratory performs immunohistochemistry for estrogen receptor (ER) and/or progesterone receptor (PgR) as a prognostic/predictive marker on breast carcinoma, the laboratory has documented appropriate validation for the assay(s)., NOTE: Initial test validation should include a minimum of 40 cases (20 positive and 20 negative cases) for FDA-cleared/approved tests; laboratories should consider using higher numbers of test cases if a Laboratory Developed or Laboratory Modified Test is to be validated. Validation should be performed by comparing the laboratory’s results with another assay that has been appropriately validated. Acceptable concordance levels are 90% for positive results and 95% for negative results.
If significant changes are made to the testing methods (e.g. antibody clones, antigen retrieval protocol or detection system), revalidation is required.
This requirement is applicable to both new and existing assays. If review of the initial validation does not meet the current standard, it must be supplemented and brought into compliance. It is possible to do this retroactively by review and documentation of past proficiency testing challenges or by sending unstained slides from recent cases to a reference laboratory for correlation. If no documentation exists from the initial validation, the assay must be fully revalidated and documented., “
ANP.22978, HER2 Assay Validation
“If the laboratory performs HER2 testing (HER2 protein over-expression by immunohistochemistry or HER2 gene amplification by in situ hybridization [e.g. FISH, CISH, SISH, etc.]), the laboratory has documented appropriate validation for the assay(s)., NOTE: This requirement applies to both new and existing assays. Initial test validation must be performed on a minimum of 20 positive and 20 negative samples for FDA-cleared/approved assays; or 40 positive and 40 negative samples for laboratory-developed tests (LDTs). Equivocal samples need not be used for validation studies. If the initial validation of existing assays does not meet the current standard, it must be supplemented and brought into compliance. It is permissible to do this retroactively by review of performance on past proficiency testing challenges or by sending unstained slides from recent cases to a reference laboratory for correlation. If no documentation exists from the initial validation, the assay must be fully revalidated and documented.
Validation may be performed by comparing the results of testing with a validated alternative method (i.e. IHC vs. FISH) either in the same laboratory or another laboratory, or with the same validated method performed in another laboratory; validation testing must be done using the same set of cases in both labs. The validation documentation should identify the comparative test method(s) used.
The validation data should clearly show the degree of concordance between methods (e.g. for IHC: 0, 1+, 3+; for FISH, CISH, SISH: positive, negative, as defined by the cut-offs listed in the latest version of the CAP/ASCO guideline).
The characteristics of the cases used for validation should be similar to those seen in the laboratory’s patient population (i.e. core biopsies vs. open biopsy material, primary vs. metastatic tumor, etc.).
Samples used for validation must be handled in conformance with the guidelines in this checklist. If specimens are fixed in a medium other than 10% neutral buffered formalin, the validation study must show that results are concordant with results from formalin-fixed tissues.
If significant changes are made in testing methods (e.g. antibody clone, antigen retrieval protocol or detection system, FISH probe or pretreatment protocol), revalidation is required.
This checklist requirement applies to laboratories that perform the technical testing of specimens for HER2 amplification. Patient specimens should be fixed in the same manner as the specimens used for the validation study(ies).
This requirement is applicable to both new and existing assays. If review of the initial validation does not meet the current standard, it must be supplemented and brought into compliance. It is possible to do this retroactively by review and documentation of past proficiency testing challenges or by sending unstained slides from recent cases to a reference laboratory for correlation. If no documentation exists from the initial validation, the assay must by fully revalidated and documented.
*CISH = chromogenic in-situ hybridization; SISH = silver-enhanced in-situ hybridization, “
ANP.22979, HER2 Testing
At least one tumor sample from all patients with breast cancer (early-stage, recurrent, or metastatic disease) is tested for either HER2 protein expression (IHC assay) or HER2 gene expression (ISH assay) using a validated HER2 test if tissue is available., NOTE: HER2 testing should be repeated on another specimen or block if: 1) the initial HER2 result is discordant with the histologic features of the tumor, or 2) in a core biopsy, the initial result is negative when the amount of tumor used for testing was limited, or the result is equivocal by IHC and ISH.,
ANP.22983, HER2; ER/PgR - Fixation
“If the laboratory assesses HER2 protein over-expression by immunohistochemistry, HER2 gene amplification by in situ hybridization, or estrogen/progesterone receptor expression by immunohistochemistry, there is a documented procedure to ensure appropriate specimen fixation time., NOTE: Specimens subject to these tests should be fixed in 10% neutral buffered formalin for at least 6 hours and up to 72 hours. The volume of formalin should be at least 10 times the volume of the specimen. Decalcification solutions with strong acids should not be used. For cases with negative HER2 results by IHC that were fixed outside these limits, consideration should be given to performing confirmatory analysis by in-situ hybridization.
Laboratories should communicate the following fixation guidelines to clinical services:
- Specimens should be immersed in fixative within 1 hour of the biopsy or resection procedure
- If delivery of a resection specimen to the pathology department is delayed (e.g. specimens from remote sites), the tumor should be bisected prior to immersion in fixative. In such cases, it is important that the surgeon ensure that the identity of the resection margins is retained in the bisected specimen; alternatively, the margins may be separately submitted.
- The time of removal of the tissue and the time of immersion of the tissue in fixative should be recorded and submitted to the laboratory
Communication may be through memoranda, website, phone, face-to-face meetings, or other means. The laboratory should consider monitoring compliance and contacting clients when these guidelines are not met.
If specimens are fixed in a medium other than 10% neutral buffered formalin, the laboratory must perform a validation study showing that results are concordant with results from formalin-fixed tissues.
Laboratories testing specimens obtained from another institution should have a policy that addresses time of fixation. Information on time of fixation may be obtained by appropriate questions on the laboratory’s requisition form.
Reports should qualify any negative results for specimens not meeting the above guidelines., “
ANP.22985, Predictive Marker Testing - Decalcified Tissue
If the laboratory performs FISH and/or immunohistochemistry for ER, PgR, and/or HER2 on decalcified tissues, the results include a disclaimer noting that these assays have not been validated on decalcified specimens., NOTE: Separate validation for ER, PgR, and/or HER2 testing on decalcified specimens is not feasible for most laboratories. As such, a disclaimer should be included in the surgical pathology report which may read, “This assay has not been validated on decalcified tissues. Results should be interpreted with caution given the likelihood of false negativity on decalcified specimens.,
ANP.22999, HER2 by IHC - Scoring
If the laboratory interprets HER2 protein over-expression by immunohistochemistry (IHC), results are reported using either the manufacturer’s instructions or the ASCO/CAP scoring criteria., NOTE: The report should note which method of scoring is used, and if ASCO/CAP scoring criteria are used, the report includes the ASCO/CAP reference including the year of publication.,
ANP.23002, HER2 by ISH/FISH - Scoring
“If the laboratory interprets HER2 gene amplification by in situ hybridization (e.g. FISH, CISH, SISH), results are reported using either the ASCO/CAP scoring criteria or the manufacturer’s instructions., NOTE: The table below contains the ASCO/CAP scoring criteria used to determine HER2 gene status by in-situ hybridization.
Careful attention should be paid to the recommended exclusion criteria for performing or interpreting in situ hybridization for HER2 (e.g. signal obscured by background; for FISH, difficulty in defining areas of invasive carcinoma under UV light).
Variable ISH positivity (heterogeneity) must also be considered when analyzing ISH studies. ISH slides are scanned at low power prior to counting to determine if there is a discrete population of amplified cells representing more than 10% of the invasive tumor cells in that area; such cases are reported as HER2 positive (amplified).
For FDA-cleared/approved test systems that use different scoring criteria, the manufacturer’s instructions must be followed.
**Criteria in both columns must be met for tests with internal control probes. For example, for a result to be negative, the ratio must be
ANP.23003, Receptor Reporting
“Immunohistochemical estrogen receptor and/or progesterone receptor test results are reported using the ASCO/CAP scoring criteria., NOTE: The ASCO/CAP scoring guidelines are as follows:
- A positive test is defined as positive staining of greater than or equal to 1% of tumor cell nuclei.
- A negative test is defined as staining of less than 1% of tumor cell nuclei.
- The report includes the percentage/proportion of positive-staining tumor cells. The percent of positive-staining tumor cell nuclei may be determined by estimation or quantification.
- In addition to the above, for positive tests the report includes an estimate of the intensity of staining over the entire tumor present on the tissue section. Staining intensity is reported as weak moderate or strong.*
- A test result is defined as ““indeterminate”” if there is a problem in specimen handling, processing or staining that compromises test reliability, in the judgment of the pathologist.
The laboratory should consider adding a qualifying note to the test report, when, 1) there are negative results for tumor types that are usually positive–for example, invasive tubular, lobular and mucinous carcinomas, and low grade invasive carcinomas; 2) the estrogen receptor test is negative and the progesterone receptor test is positive (which raises the possibility of a false negative estrogen receptor test, or a false positive progesterone receptor test); 3) results are negative in a breast specimen, in the absence of internal controls; 4) there is weak staining, or staining of few cells, in a small sample (e.g. less than 100 tumor cells). In the above four circumstances, consideration should be given to repeating the test on a different tissue block, if available, or resection specimen.
For specimens containing both duct carcinoma in situ (DCIS) and invasive carcinoma, estrogen receptor, and progesterone receptor tests should be scored only for the invasive component. The staining status of the DCIS component may be reported in a comment, at the option of the pathologist.
*Calculation of an intensity score (e.g. Allred, H or Quick score) is optional., “
ANP.23004, Preanalytic Documentation
There is documentation that the preanalytic phase of the test system has been validated for each assay, including definition of acceptable specimen preservation, fixation and processing, and definition of how microscopic fields are selected for analysis., NOTE: Test results may be affected by fixation parameters including time of fixation and the type of fixative used, and by hemorrhage, necrosis, and autolysis of tissue.,
ANP.23009, Calibration
“Appropriate slides are used for calibration., NOTE: There are two types of image analysis systems in current use in anatomic pathology. The first evaluates pixels without regard for pixel location (e.g. nucleus, cytoplasm, extracellular areas, etc.). The second initially identifies objects (the nucleus, for example) in an image and then classifies the object as positive or negative.
For pixel-based systems, calibration is accomplished by use of a slide that includes all of the possible intensity values that a pixel can occupy; this slide is then run for verification of calibration. For some systems, the vendor provides the calibration slide and calibration must be verified before a patient sample can be analyzed.
For object-based systems, calibration must address two processes: 1) capturing or ignoring objects, as appropriate; and 2) correct classification of captured objects, with establishment of the minimum threshold for scoring an object as positive. Typically calibration slides are used to adjust for object detection based on minimum or maximum size, shape, etc. Then the minimal staining threshold is established for classifying an object as positive, by comparing to background staining and counter staining for each run of patient specimens. A weakly expressed antigen should be used to establish the threshold (e.g. secretory endometrium for estrogen receptor). The calibration of the imaging system may be confined to the type of analysis e.g. nuclear, membrane or cytoplasm, etc.
Calibration should include adjustment of light output, if applicable, to ensure that output is matched to the sensor’s dynamic range.
(This requirement does not apply to systems that feature ““internal calibration.”” The Quality Control requirements below, however, do apply.), “
ANP.23018, Daily QC
Control materials at more than one expression (level) are run concurrently with patient specimens., NOTE: Controls should check test performance at relevant decision points. For many tests, a positive and a negative control are sufficient. Controls need be run only on days when patient specimens are tested. For immunohistochemistry, the laboratory must follow the control requirements in the Immunohistochemistry section of this checklist.,
ANP.23020, QC Handling
Control specimens are tested in the same manner and by the same personnel as patient/client samples., NOTE: QC specimens must be analyzed by personnel who routinely perform patient/client testing - this does not imply that each operator must perform QC daily, so long as each instrument and/or test system has QC performed at required frequencies, and all analysts participate in QC on a regular basis. To the extent possible, all steps of the testing process must be controlled, recognizing that pre-analytic and post-analytic variables may differ from those encountered with patient/clients.,
ANP.23021, Positive Threshold Level
A negative control is used to ensure that non-staining areas are scored as negative., NOTE: The negative control may be a separate slide or an area on the patient test slide that is known to be negative.,
ANP.23022, QC Confirmation of Acceptability
The results of controls are reviewed for acceptability before reporting results., NOTE: Control results must be reviewed before reporting patient/client results. It is implicit in quality control that patient/client test results will not be reported when controls do not yield acceptable results.,
ANP.23025, Monthly QC Review
“Quality control data are reviewed and assessed at least monthly by the laboratory director or designee., NOTE: The review of quality control data must be documented and include follow-up for outliers, trends, or omissions.
The QC data for tests performed less frequently than once per month should be reviewed when the tests are performed., “
ANP.23027, Area of Analysis
A qualified pathologist selects the appropriate areas for analysis., ,
ANP.23028, Analysis Guidelines
There are documented guidelines for identification of appropriate areas and cells for analysis., NOTE: Evaluation of heterogeneous cell populations requires use of specific guidelines and procedures, particularly if there is background or nonspecific staining, or if there is cell debris, endogenous pigment, and/or artifacts of aging, sectioning or preparation. ,
ANP.23031, Histogram Acceptability Criteria
There are documented criteria for acceptability of histograms for interpretation., NOTE: The histogram should represent a statistically relevant and representative sample of cells. The characteristic contour of a cell cycle should be evident. There should be a sufficient number of stem-line events to permit accurate S-phase determination and a limit on background debris.,
ANP.23033, G0/G1 Peak
Appropriate internal or external control cells of known DNA content are evaluated with each specimen or batch of specimens to establish an acceptable coefficient of variation for the G0/G1 peak., ,
ANP.23034, Aneuploid Cell Population ID
“Criteria are established for identification of an aneuploid cell population in the test specimen., NOTE: Detection of DNA aneuploidy depends largely on the ability of the test system to resolve one or more peaks in the histogram that are separate from the non-neoplastic cells that are present. Resolution of separate peaks is dependent upon the coefficient of variation (CV) of the analysis, which is in turn highly dependent upon the tissue type, the manner in which the specimen is prepared and the relative frequency of non-neoplastic cells. Periodic evaluation of the CV’s for control cells is necessary to ensure adequate resolution of the test system.
In paraffin-embedded tissue, the position of the diploid peak is variable, depending on the processing techniques. In the event that only one G0/G1 peak is found, it is assumed to be diploid unless morphologic assessment indicates otherwise. In the event of more than one peak, if the relative DNA content cannot be determined to be DNA hypodiploid or DNA hyperdiploid, the paraffin section must be re-processed, accompanied by the processing of multiple blocks each containing variable proportions of normal and neoplastic tissue from the same patient, as defined morphologically by the pathologist. , “
ANP.23036, Final Report Interpretation
The final report includes an interpretation by the responsible pathologist., NOTE: Interpretation requires correlation with the light microscopic features such as routine histology, immunohistochemistry, cytologic material, cytogenetic and molecular studies, and/or clinical information.,
ANP.23037, Final Report Elements
The final report includes the criteria for positive and negative results including reference range., NOTE: The reference range may be determined by the laboratory’s validation of the test system, or through evaluation of manufacturer’s or other published information.,
ANP.23038, Final Report Elements
The final report includes the specimen source, name of the vendor and imaging system used, the antibody clone or probe, and the detection method, as well as any limitations of the test result, if applicable., NOTE: For DNA staining, the CV (coefficient of variation) should be included in the patient report.,
ANP.23041, Testing Personnel Qualifications
Personnel who operate the imaging system are qualified as high-complexity testing personnel., NOTE: The qualifications to perform high complexity testing can be accessed using the following link: CAP Personnel Requirements by Testing Complexity.,
ANP.23042, Bench Testing Supervision
The person in charge of bench testing/section supervisor for image analysis is qualified to perform high-complexity testing, with at least one year’s experience in image analysis under a qualified laboratory director., ,
ANP.23085, Pipette Accuracy - Non Class A
Pipettes that are used for quantitative dispensing of material are checked for accuracy and reproducibility at least annually, and results documented., NOTE: Such checks are most simply done gravimetrically. This consists of transferring a number of measured samples of water from the pipette to a balance. Each weight is recorded, the weights are converted to volumes, and then arithmetic means (for accuracy), and SD/CV (for imprecision) are calculated. Alternative approaches include spectrophotometry or (less frequently) the use of radioactive isotopes, and commercial kits are available from a number of vendors. Computer software is useful where there are many pipettes, and provides convenient documentation. This checklist requirement does not apply to Class A volumetric pipettes that meet the American Society for Testing and Materials calibration (accuracy) specifications.,
ANP.23100, Tissue Processor Solutions
Tissue processor solutions are changed at intervals appropriate for the workload., ,
ANP.23120, Tissue Processing Programs
“Tissue processing programs are validated., NOTE: To validate new processing programs, laboratories should run tissue samples of the same size, thickness and fixation in duplicate. Reagents on the processor(s) should be comparable, e.g. all fresh reagents. Process, embed, cut, and stain slides at the same time and evaluate the quality of the blocks, e.g. firmness, ease of cutting. The slides should be evaluated by the pathologist without knowledge of which processing program was used and graded on quality of section and staining. The new processing program must be of adequate quality before being put into use.
This method may also be used to verify a routine processing program before putting a new processor into clinical service., “
ANP.23130, Tissue Processing Programs
Specific tissue processing programs are available for different types and sizes of specimens., NOTE: To achieve acceptable results for diagnostic purposes, processing programs may be needed for different sizes and types of specimens. Biopsy specimens may be processed on a shorter schedule than larger specimens; large, dense or fatty specimens and brain specimens will not process adequately on a shorter schedule. A variety of processing programs should be used to achieve good processing results.,
ANP.23150, Paraffin Baths and Dispensers
“Paraffin baths and dispensers are properly maintained., NOTES:
- Instruments must be clean and well-maintained
- The temperature of the dispenser must be correct for the type of paraffin used, “
ANP.23350, Flotation Baths
Flotation baths are clean and well-maintained, and there is a procedure for preventing cross-contamination of paraffin sections in the bath., NOTE: Of particular importance are periodic water changes or blotting of the water surface so that sections from one patient block are not inadvertently carried over to another case (so-called “floaters” or “extraneous tissue”).,
ANP.23400, Microtome Maintenance
“Microtomes and microtome knives are clean and well-maintained., NOTES:
- Microtomes must be clean, properly lubricated, and without excessive play in the advance mechanism
- Knives must be sharp and free of nicks, “
ANP.23410, Cryostat Decontamination
There is a documented procedure for the decontamination of the cryostat at defined intervals, and under defined circumstances, and decontamination records are evident., NOTE: The cryostat must be defrosted and decontaminated by wiping all exposed surfaces with tuberculocidal disinfectant. The cryostat should be at room temperature during decontamination unless otherwise specified by the manufacturer. This should be done at an interval appropriate for the institution; this must be weekly for instruments used daily. Trimmings and sections of tissue that accumulate inside the cryostat must be removed during decontamination. Although not a requirement, steel mesh gloves should be worn when changing knife blades. ,
ANP.23700, Storage Organization
Slides and paraffin blocks are properly stored in an organized manner (i.e. accessible for retrieval, and properly identified)., NOTE: Slides and blocks should be stored in a manner to prevent contamination from blood or other fluids or tissues. The storage area for blocks should be cool to prevent blocks from melting together.,
ANP.24050, Automated Tissue Processor
“Each open (i.e. generative of flammable vapors into the ambient workspace) automated tissue processor is operated at least 5 feet from the storage of combustible materials and from the paraffin dispenser., NOTE: Tissue processors that operate as a closed system confine ignitable vapor hazards within the processor and thus do not pose a hazard requiring a 1.52 m (5 ft.) separation.
Each open (i.e. generative of flammable vapors into the ambient workspace) automated tissue processor must be located at least 5 feet from the storage of combustible materials unless separated by one-hour fire-resistive construction. Flammable and combustible liquids must not be positioned near sources of heat or ignition. At least 5 feet must separate each open system tissue processor from the paraffin dispenser., “
ANP.24100, Microtome Knife Storage
Microtome knives are stored in original containers or by some other means to avoid personnel injury or equipment damage., ,
ANP.24200, Biohazard Waste Disposal
“Infectious tissues and other potentially contaminated materials are disposed of with minimum danger to professional, technical, and custodial personnel, and to recipients., NOTE: Waste disposal must be in accord with all regulations.
Specimens returned to patients (e.g. prostheses, gallstones) or otherwise released to others (e.g. pacemaker or prosthesis to manufacturer) must be disinfected before release., “
ANP.24300, Creutzfeldt-Jakob Disease (CJD) Special Handling
“There are documented procedures for the special handling of tissues in the histology laboratory from cases in which Creutzfeldt-Jakob disease is suspected., NOTE: In addition to specimen handling, the policy should include guidelines for appropriate intralaboratory communication.
Neuropathology tissues from suspected cases of Creutzfeldt-Jakob disease should be treated with formic acid. Paraffin blocks and slides prepared from formic-acid-treated tissue may be handled routinely.
If tissue has not been treated with formic acid, it must be hand-processed and treated as containing potentially transmissible prions. Double gloves must be worn at all times when handling such tissue. All solutions, including water washes, must be collected and treated with equal volumes of fresh undiluted household bleach for 60 minutes before disposal. Disposables, glassware, tools, etc. must be handled according to the procedures employed in the autopsy room described elsewhere in this checklist. All scraps of paraffin and unused sections should be collected on a disposable sheet. The microtome may be wiped with bleach or NaOH solution. No special precautions are needed in handling intact glass slides once they have been coverslipped. Broken slides should be decontaminated and discarded. Paraffin blocks should be stored in a bag or box and labeled as infectious. Alternatively, the laboratory may reseal the cut surface of the blocks with paraffin. Additional information may be found in the Autopsy section of this checklist., “
ANP.27150, Glass Slide/Block Disposal
There are documented procedures for safe disposal of used glass slides and paraffin blocks., NOTE: The laboratory must follow CAP retention requirements for slides and blocks (refer to checklist requirement in the “Surgical Pathology Reports” section of this checklist).,
ANP.27170, Microwave Usage
Microwave devices are used in accordance with manufacturer’s instructions., NOTE: Microwave devices should be used in accordance with manufacturer’s instructions, unless CAP requirements are more stringent.,
ANP.28290, Microwave Monitoring
“Microwave devices are at least annually monitored for reproducibility., NOTE: “Reproducibility” is defined as consistency in diagnostic quality obtained from microwave equipment and procedures. For some devices, reproducibility may be evaluated by monitoring the temperatures of identical samples after microwave processing. For those microwave devices (particularly those incorporated into histology processing equipment) that use temperature-independent methods to evaluate reproducibility, the laboratory should have a written procedure for monitoring reproducibility that follows instrument manufacturer’s instructions. Information on such procedures is given in the reference to this checklist requirement (see below).
The microwave device should be tested for radiation leakage if there is visible damage to the device., “
ANP.28860, Microwave Container Venting
All containers used in microwave devices are vented., NOTE: Venting of containers is necessary so that processing occurs at atmospheric pressure, to prevent explosion. For procedures using pressure above that of the atmosphere, specialized containers must be used, with strict adherence to manufacturer instructions. ,
ANP.29430, Microwave Venting
“Microwave devices are properly vented., NOTE: This checklist item does not apply to microwave devices that are designed by the manufacturer to operate without venting.
Microwave devices should be placed in an appropriate ventilation hood to contain airborne chemical contaminants and potentially infectious agents. Before operation of the microwave device, flammable and corrosive reagents should be removed from the hood, to prevent fire or chemical damage to the electronic components of the device. Microwave devices used outside a fume hood should have an integral fume extractor that is certified by the manufacturer for use in a clinical laboratory.
The effectiveness of ventilation should be monitored at least annually.
This checklist requirement does not apply if only non-hazardous reagents (and non-infectious specimens) are used in the device (e.g. water, certain biological stains, paraffin sections). The laboratory should consult the safety data sheets (formerly MSDS) received with reagents and stains to assist in determining proper handling requirements and safe use., “
ANP.29500, Calibration
An appropriate verification/calibration system is used as appropriate to check performance prior to testing., NOTE: An appropriate process is used to check the optical and mechanical performance of the system. This may be accomplished using the manufacturer’s provided material. Manufacturer’s instructions must be followed regarding when and how often the verification/calibration is performed.,
ANP.29510, Recalibration
The test system is recalibrated when calibration verification fails to meet the established criteria provided by the manufacturer., ,
ANP.29520, Daily QC
Control materials at more than one level are run each day of patient testing., ,
ANP.29530, QC Handling
Control specimens are tested in the same manner and by the same personnel as patient/client samples., NOTE: QC specimens must be analyzed by personnel who routinely perform patient/client testing; this does not imply that each operator must perform QC daily, as long as each instrument and/or test system has QC performed at required frequencies, and all analysts participate in QC on a regular basis. To the extent possible, all steps of the testing process must be controlled, recognizing that pre-analytic and post-analytic variables may differ from those encountered with patient/clients.,
ANP.29540, QC Confirmation of Acceptability
The results of controls are reviewed for acceptability before reporting results., NOTE: Control results must be reviewed before reporting patient/client results. It is implicit in quality control that patient/client test results will not be reported when controls do not yield acceptable results.,
ANP.29550, Monthly QC Review
“Quality control data are reviewed and assessed at least monthly by the laboratory director or designee., NOTE: The review of quality control data must be documented and include follow-up for outliers, trends, or omissions that were not previously addressed.
The QC data for tests performed less frequently than once per month should be reviewed when the tests are performed., “
ANP.29560, Specimen Rejection Criteria
There are documented criteria for the rejection of unacceptable specimens, instructions for the special handling of sub-optimal specimens, and documentation of disposition of all unacceptable specimens in the patient/client report and/or quality management records., NOTE: This requirement does not imply that all “unsuitable” specimens are discarded or not analyzed. If, for example, improper storage hemolyzes a sample and hemolyses interferes with testing, there must be a mechanism to notify clinical personnel responsible for patient care. If the treating physician desires the result, then the laboratory must note the condition of the sample on the report. Some or all tests may not be analytically valid on such a specimen. The laboratory may wish to record that a dialogue was held with the physician, when such occurs.,
ANP.29570, Carryover Detection
There is a procedure for detection and evaluation of potential carryover., NOTE: The procedure must address criteria for the evaluation of potential carryover from a preceding elevated (high concentration) sample to the following sample in each analytical batch analysis and appropriate actions (e.g. wash cycle) to be taken. ,
ANP.29580, Analysis Guidelines
There are documented guidelines for differentiating circulating tumor cells from other nucleated circulating cells, such as leukocytes, as well as other cellular debris., NOTE: Evaluation of circulating tumor cells requires the use of specific guidelines and procedures to distinguish circulating tumor cells from white blood cells and other artifacts.,
ANP.29590, Report Review
All reports are reviewed and signed by the pathologist., NOTE: The inspector must review a sampling of reports issued since the previous on-site inspection, representing at least the most common types of specimens seen in the laboratory. When diagnostic reports are generated by computer or telecommunications equipment, the actual signature or initials of the pathologist may not appear on the report. It is nevertheless essential that the laboratory have a procedure that ensures and documents that the responsible pathologist has reviewed and approved the completed report before its release. In the occasional situation when the diagnosing pathologist is not available for timely review and approval of the completed report, the laboratory may have a policy and procedure for review and approval of that report by another pathologist. In that circumstance, the names and responsibilities of both the pathologist who made the diagnosis and the pathologist who performs final verification must appear on the report.,
ANP.29600, Final Report Elements
The final report includes the criteria for favorable and unfavorable results., NOTE: The range determining favorable and unfavorable results may be determined by the laboratory’s validation of the test system, or through evaluation of manufacturer’s or other published information.,
ANP.29610, Final Report Elements
The final report includes the specimen source, name of the vendor and analyzer used, as well as any limitations of the test result, if applicable., ,
ANP.29620, Morphologic Observation Assessment
“The laboratory at least annually assesses morphologic observations among non-pathologist personnel performing CTC analysis, to ensure consistency. , NOTE: Suggested methods to accomplish this include:
- Circulation of images with specific qualitative abnormalities for the different cell populations evaluated
- Use of digital images, “
ANP.29630, Testing Personnel Qualifications
Personnel who operate the analyzer are qualified as high-complexity testing personnel., NOTE: The qualifications to perform high complexity testing can be accessed using the following link: CAP Personnel Requirements by Testing Complexity.,
ANP.29640, Bench Testing Supervision
The person in charge of bench testing/section supervisor for circulating tumor cell analysis is qualified to perform high-complexity testing, with at least one year’s experience in CTC analysis, or equivalent, under a qualified laboratory director., NOTE: In lieu of one year of experience in CTC analysis, the person in charge of bench testing/section supervisor can demonstrate successful completion of a CTC analysis training program offered by the instrument manufacturer. ,
ANP.30100, Postmortem Clinicopathological Correlations
“The findings of the postmortem examination are used for correlative clinicopathological teaching purposes that are designed to enhance the quality of patient care., NOTE: The autopsy has an important role in medical education and quality improvement. The value of the final autopsy report is enhanced when the findings are used for teaching that emphasizes clinicopathological correlations. This teaching activity should be documented and may take any of several forms, including a correlative note in the autopsy report, interdepartmental note or summary, or a clinical teaching conference.
Autopsy findings that were clinically unapparent but important should be specifically documented in the report. Inter-departmental communication of such findings may, in addition, also be accomplished via presentation at an inter-departmental conference., “
ANP.30150, Autopsy QM
The findings from autopsies are incorporated into the institutional quality management program., NOTE: Some examples of this could include: 1) reporting newly diagnosed infectious diseases to the hospital infection prevention committee, 2) presentation and/or review by institutional quality assurance committees, 3) reporting issues related to quality of care to risk management or sentinel event review committees.,
ANP.31070, Autopsy Consent
There is a documented procedure for obtaining autopsy consent, including who may give consent., ,
ANP.31100, Medical Examiner Jurisdiction
There are instructions covering possible medical examiner or coroner jurisdiction over hospital deaths to assess the appropriateness of performing a hospital autopsy., NOTE: To assess the appropriateness of performing a hospital autopsy, the department must be familiar with applicable statutes and/or regulations that identify hospital deaths subject to medical examiner or coroner jurisdiction. The department should maintain a copy of applicable statute(s) and/or regulation(s) that identify those deaths that are in the jurisdiction of the medical examiner and/or coroner.,
ANP.32200, Adequate Space and Lighting
There is sufficient space and the autopsy room is clean and well-maintained, with adequate lighting., NOTE: The space should be sufficient for the workload requirements of the service. The autopsy room should be dedicated to the performance of autopsies. Other functions (e.g. storage teaching, tissue procurement) should not interfere with the safe performance of the autopsy and the cleaning of the facility.,
ANP.32400, Adequate Storage
Provisions are available for satisfactory storage of bodies (refrigeration or embalming)., NOTE: For refrigeration, the temperature should be in the range of 34-40º F (1.1-4.4º C).,
ANP.32450, Scale/Balance
A scale and/or balance are provided for reliable weighing of organs., NOTE: If infants or fetuses are autopsied at the institution, accuracy of balances to 1.0 gm for infants and 0.1 gm for fetuses must be documented by periodic calibration.,
ANP.32500, Temperature and Ventilation
Ambient temperature and ventilation control are adequate., NOTE: Airborne infectious agent control requires appropriate ventilation.,
ANP.32550, Photographic Equipment
Photographic equipment is available, convenient, and functional., ,
ANP.33000, Clinical Record Review
Available clinical records are reviewed and/or clinical information discussed with the attending physician or clinical housestaff/fellows before conducting the autopsy., ,
ANP.33025, Patient Identity Confirmation
The identity of deceased patients is confirmed prior to beginning the autopsy., ,
ANP.33050, Autopsy Performance
All autopsies are performed or supervised by a pathologist who is board certified in anatomic pathology, or possesses qualifications equivalent to those required for certification in anatomic pathology., ,
ANP.33100, Preliminary Reports
A documented preliminary report of the gross pathologic diagnoses is submitted to the attending physician and the institutional record in 90% of the cases within a reasonable time., NOTE: For preliminary reports based on gross examination only, two working days is the recommended TAT. For cases with complicated dissections or rush histology, up to 4 working days is recommended. For some cases such as single organ only examination or slide consults, a Provisional Report may not be appropriate or required.,
ANP.33120, Final Report TAT
The final autopsy report is produced within 60 working days in 90% of the cases., NOTE: The 90% threshold is used in recognition of the fact that occasional unusual cases may require more than 60 days for completion, particularly when external consultation is required. If cases exceed 60 days, there should be documentation of the reason for the delay and of ongoing review of this information by the director of the service.,
ANP.33200, Gross and Microscopic Descriptions
Gross descriptions are clear and pertinent findings are adequately described. If microscopy is performed, microscopic descriptions are included in the report and a key of block and/or slide designations is included to identify the source of specific microscopic sections., NOTE: At a minimum, the key should include information on laterality and on specific lesions sampled. Annotated drawings and photographs are valuable tools for documenting the autopsy findings, but are not adequate replacements for a text description.,
ANP.33350, Final Report Content
The final autopsy report contains sufficient information in an appropriate format so that a physician may ascertain the patient’s major disease processes and probable cause of death., ,
ANP.33400, Autopsy Records
Autopsy records are organized and readily available for review and are entered into a database to allow for retrieval of cases by diagnosis., NOTE: At the facility’s discretion, the database may be a card file, log book, or an electronic record, depending on the size of the database.,
ANP.33500, Record Retention
“Autopsy pathology records and materials are retained for an appropriate period., NOTE 1: There must be a documented policy for preserving the integrity of retained autopsy service materials. The laboratory must define the period of time that such materials are retained. The retention period shall be sufficient for use of the materials in the institution’s quality improvement activities (e.g. morbidity and mortality conferences). In establishing retention requirements, care should be taken to comply with state and federal regulations. Minimum requirements for autopsy pathology, providing these are not less stringent than state and federal regulations, are:
- Accession log records - 2 years
- Wet tissue (stock bottle) - 3 months after final report
- Paraffin blocks - 10 years
- Glass slides and reports - 10 years
NOTE 2: Regarding release of blocks for research purposes: Federal regulations require that a laboratory retain paraffin blocks for two years unless the tissue is blocked specifically for research and not used for patient diagnostic purposes. The CLA requires, however, that paraffin blocks used for patient diagnostic purposes must be kept for at least 10 years. Nevertheless, such blocks may be released for research purposes after the two-year regulatory requirement if all of the following criteria are met:
- For a laboratory subject to U.S. law, formal written authorization is obtained in accordance with the requirements of HIPAA if identifiable patient information is released unless, in accordance with 45CFR164.512(i), the laboratory obtains from the researcher a representation that use of the blocks protects the health information of decedents
- The laboratory retains sufficient blocks to support the diagnosis for the full 10-year period.
- Provision is made for retrieval by the laboratory of any blocks or material that remain after use in research, if the blocks or material are needed for diagnostic, legal, or other legitimate purposes.
- The laboratory meets other relevant requirements including but not limited to the requirements of the institution, the directives of any applicable institutional review board (IRB) or similar entity; and state and local laws and regulations., “
ANP.33650, Autopsy Facilities
Appropriate facilities, equipment and instruments are available to meet safety policies and procedures., NOTE: Containers must be available for contaminated waste and hazardous chemicals and policies must be in place for their disposal. Equipment and apparel must be available to provide protection to eyes, hands, and skin surfaces from direct and aerosolized exposures during autopsy performance. Procedures must be in place for the disposition or cleaning of these items for re-use upon completion of the autopsy.,
ANP.34000, Safety
There is appropriate signage at entries to the autopsy laboratory warning of the potential presence of hazardous chemicals and biologic materials, and the need for universal precautions. Policies and procedures for contaminated cases/specimens, hazardous chemicals, etc. are written and posted in the autopsy suite., NOTE: It is important that persons entering the autopsy laboratory be aware of potential hazards and take appropriate protective measures. Postings may include information such as details of personal protective equipment and emergency contact information.,
ANP.34050, Decontamination
The safety policies and procedures provide instructions for daily cleaning, cleaning after an autopsy, proper handling of highly infectious cases, and disposal of tissues., NOTE: Tables and reusable instruments and aprons must be adequately disinfected after use. Either autoclaving or chemical disinfection of instruments is acceptable, but the method chosen must be adequate to inactivate the hepatitis B virus.,
ANP.34150, Creutzfeldt-Jakob Disease (CJD) Special Handling
“There are documented procedures for the special handling of cases in which Creutzfeldt-Jakob disease is suspected., NOTE: In addition to practicing universal precautions during the autopsy, procedures must be written for the special precautions to be taken for autopsies on patients in whom the diagnosis of Creutzfeldt-Jakob disease is suspected. Pathologists should consider taking these special precautions as well in cases of (a) rapidly progressive dementia, (b) dementia with seizures, especially myoclonic seizures, and (c) dementia associated with cerebellar or lower motor neuron signs. The recommended method for handling these brains to reduce infectivity is immersion of tissue blocks in 95% formic acid. Aerosol formation must be avoided during removal of the brain.
If there is any suspicion of Creutzfeldt-Jakob disease, the autopsy should be limited to the brain, and the tissue treated as outlined below. There should be very few exceptions to this rule.
Autopsy brain tissues should be handled as follows:
The intact brain is fixed in formalin for 1-2 weeks before cutting. Tissue blocks (representative regions of neocortex, basal ganglia, and cerebellum) are taken, agitated in at least 50-100 mL of 95-100% formic acid for 1 hour, and then returned to formalin for 2 days before embedding. Alternatively, one may take the necessary diagnostic sections from the fresh brain, fix them in formalin for 2-7 days, treat with formic acid for 1 hour, fix again in formalin for 2 days, and then embed in paraffin. This method significantly reduces infectivity.
At the conclusion of the autopsy, the area of incision and other contaminated skin surfaces are washed with freshly opened undiluted commercial household bleach (sodium hypochlorite). As sodium hypochlorite deteriorates after several months, a newly opened container should be used for each autopsy. After 10 minutes, the skin may be washed with water. All gowns, gloves, plastic sheets, and other disposable supplies are placed in a red or orange biohazard bag and incinerated. Alternatively, they may be autoclaved (132º C steam) and discarded. Hard surfaces are decontaminated with freshly opened undiluted bleach or NaOH. 1N NaOH is adequate unless there will be dilution by surface liquid, in which case 2N NaOH should be used. Bleach and NaOH are equally effective, but NaOH is preferred for steel instruments and surfaces because it is less corrosive than bleach. The disinfectant should remain in contact with the surface for at least 15 and preferably 60 minutes. Autopsy instruments should have any visible blood removed, then decontaminated with undiluted bleach or 1-2N NaOH as above. Alternatively, they may be autoclaved for 1 hour at 132º C and 20 psi.
For information on handling slides and blocks, refer to the checklist requirement in the Histology Laboratory Safety section of this checklist., “
ANP.52000, Specimen ID
The identity of every specimen and image, including blocks, slides, and electron micrographs, is maintained through each step in processing., NOTE: Each block of tissue must be individually labeled with unique patient identifier(s), e.g. accession number etched onto the block or embedded into it. Storage of unlabeled blocks in separate containers that are labeled with patient number or name does not meet this requirement.,
ANP.52100, Tissue Section Review
Sections of embedded tissue (face sections) are reviewed by the pathologist to ensure that appropriate areas are selected for electron microscopic examination., ,
ANP.52150, Tissue Section Review
Where appropriate, one micron sections (prepared after trimming or ultra thin sectioning) are also reviewed by the pathologist to ensure that appropriate areas have been selected., NOTE: An example might be a mesenchymal neoplasm where confusion between tumor cells and admixed stromal elements could occur.,
