I have been reading the post to this question and it seems to me that there are different standards depending on the lab that is operating the methodology. I do agree that the core lab for years have had the instruction and training in the performance of validation. One thing that comes to mind as well is why has histology not had this training? Why are we not getting this from our certification agency, our professional societies and biggest reason where is our standardization. It seems to me that with all these regualtions in plac for so long, why were we missed. Is it because when inspected through CAP we are being inspected by a pathologist rather than a histo tech? These are some of the questions at hand. I to see new standards within the CAP checklist as well as other regulatory organizations that will affect the future of the Anatomic Pathology community. But I think we need is to provide a underlying architecture for our peers, so that we can begin the transition to the future. This is only the beginning, there is still Digital Image Analysis and Telepathology. It funny we are looking to become a hybrid of radiology and the core lab, but with the best of both worlds. Tim great structure for the validation study.
-----Original Message----- From: histonet-boun...@lists.utsouthwestern.edu on behalf of Morken, Tim Sent: Wed 6/23/2010 9:48 AM To: histonet@lists.utsouthwestern.edu Subject: RE: [Histonet] New CAP question ANP.22760 Joe, You wrote : The folks in the 'clinical' lab have been performing more comprehensive and complex validation procedures for a very long time ..." Those were my thoughts exactly. While the person replying may or may not have specific histology experience she will have clinical lab experience (however, my guess is that she is exposed to histology regularly at CAP). Clinical labs have a bit of an easier time, actually, because they validate primarily to known concentration controls - analytical controls manufactured at a range of known concentrations for instance. The institution then adds in their normal controls for validation. As far as the current question about validating a new lot of reagent the best practice is to run parallel tests on the same machine. If that is not easily possible on a particular manufacturer's instrument then the question should be asked of them: Why not? If this is a requirement the manufacturer should provide an easy path to meeting the requirement. However, if that is not the case then the institution simply writes a procedure to get around the inadequacies of the instrument (Maybe the vendor can help with that). Then follow the procedure. That should satisfy inspectors. An "...appropriate panel of tissues..." is whatever the institution deems appropriate for the given antibody or reagent. This is a perfect place for tissue arrays. You can make your own or buy them. IHC must meet CLIA validation guidelines but since IHC is generally qualitative the requirements must be understood and methods adapted to a qualitative scenario. Several IHC and Histotechnology books discuss the subject at length (Taylor, Dabbs, Bancroft for instance). Below is a brief overview of how to do that. (for more in-depth info this was covered in an NSH teleconference I gave last year - PowerPoint, audio and references available from NSH-, and will be covered in a similar workshop at NSH in Seattle this year). 1) CAP General Validation CAP GEN.42020-42163 Test Method Validation Follows CLIA CFR Sec 493.1253 Does not apply well to IHC (IHC is usually qualitative) But the general principle applies: The laboratory must have data on each test's accuracy, precision, analytic sensitivity, interferences and reportable range. Unmodified FDA-cleared or approved tests: the lab may use manufacturer information or published reports but lab must verify outside data. Non-FDA cleared: Lab MUST verify or establish analytic accuracy, precision, sensitivity, specificity and reportable range. 2) Validation includes: Accuracy: Compare results with New antibody to a previously validated antibody on the same tissues Precision: Test samples with varying antigen expression Intra-run, Inter-run tests, 10 slides each (reproducibility) Sensitivity: True Positive vs False Negative (higher % FN = less sensitive) Interferences [Specificity]: True Negative vs False Positive (Higher % FP = less specific) Delineate what could interfere to give a false positive or false negative result. Reportable Range Establish a scoring system Provide the definition of a positive result 3)Sensitivity Analytic Sensitivity: Lowest amount of substance detectable by the test Can only be done with controls of known concentration Diagnostic Sensitivity: Ability of the test to determine true diagnostic positive verses false negative (higher % FN = less sensitive) Requires comparison to a previously validated antibody IHC Sensitivity: Extent to which an antibody can be diluted and still achieve target recognition. NOTE: This is determined by antibody AND detection system! 4) Specificity: Analytic Specificity Accuracy on tests of known positive and negative controls Controls of known concentration Determine what could "Interfere" to confound the result Diagnostic Specificity Ability of a test to determine true diagnostic negative verses false positives (Higher % FP = less specific) Requires comparison to a previously validated antibody IHC Specificity Ability of an antibody to bind exclusively to its particular antigen in the absence of staining of other molecules Or, staining of other structures in addition to target structures/cells (Sensitivity and Specificity adapted from: Theoretical and Practical Aspects of Test Performance, in Immunomicroscopy, Taylor & Cote, 2005) Tim Morken Supervisor, Histology / IPOX UCSF Medical Center San Francisco, CA -----Original Message----- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of jmye...@aol.com Sent: Tuesday, June 22, 2010 6:51 PM To: tjas...@copc.net Cc: histonet@lists.utsouthwestern.edu Subject: RE: [Histonet] New CAP question ANP.22760 Tom: As much as I agree with your acknowledgment that its seems a bit odd for the CAP to have a blood-banker responding to AP-related issue, I'm actually not surprised. The folks in the 'clinical' lab have been performing more comprehensive and complex validation procedures for a very long time, and they wonder why IHC isn't expected to follow the same requirements as chemistry, immunology, etc. -- IHC is, after all, an awful lot like ELISA. And rightfully so, because IHC is, under CLIA (which supersedes CAP), considered highly-complex, non-waived testing -- and is, therefore, subject to the same Quality Systems regulations (in particular, 42CFR493.1252-1256, 1273, and 1281) as the testing performed in other areas of the lab. Could it be that, because AP produces qualitative results that are interpreted by a pathologist and CP produces quantitative results that are interpreted by an analyzer, we somehow think that CLIA rules don't apply to IHC? I certainly don't have the answer to that, but it make me wonder what the future holds. As witnessed by some of the newest CAP 'standards' (including the question in question...no pun intended), e.g. ER/PR, where a minimum of 20 positive and 20 negative specimens must be tested, and where 10 of the positives must be weakly positive -- an acknowledgment that validation specimens must be carefully selected in order to obtain appropriate results), it certainly doesn't appear that the regulation of IHC testing is going to become more relaxed. Joe Myers, M.S., CT(ASCP) ------------------------------ Message: 12 Date: Fri, 18 Jun 2010 12:38:07 -0700 From: "Thomas Jasper" <tjas...@copc.net> Subject: RE: [Histonet] New CAP question ANP.22760 To: "Mark Tarango" <marktara...@gmail.com> Cc: _histo...@lists.utsouthwestern.edu_ (mailto:histonet@lists.utsouthwestern.edu) Mark, Did you notice the credentials from this CAP representative? MT with a Blood Bank specialty I believe. What I glean from that is...more than likely this person does not grasp the logistics of "contemporaneously" staining identical Abs from separate lots. She also likely does not understand the logistical application for detection and automation either. I'm not trying to be overly critical of this person. I'm sure she is quite intelligent and would not have the MT/SBB if she wasn't intelligent. It comes down to a lack of understanding Anatomic Pathology testing application re: automated IHC. I believe this is a common problem in and out of CAP. Many lab directors and other folks in positions of authority without AP/Histology/Cytology backgrounds seem to believe that broad clinical lab modalities apply to Anatomic Path scenarios. I used to refer to this in my former position as - "Trying to put the yoke of clinical lab onto anatomic path." We are laboratorians, but in many instances do not fit the general clinical lab mold. It's unfortunate that CAP has put this person in the position to respond. It is apparent to me that she's not grasping the particulars here. She probably never will unless she decides to go into a working, automated IHC "tissue" lab and take the time to ask questions and understand (learn) what we're all about. Thanks, Tom Jasper Thomas Jasper HT (ASCP) BAS Histology Supervisor Central Oregon Regional Pathology Services Bend, OR 97701 _______________________________________________ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet _______________________________________________ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet ______________________________________________________________________ This message is confidential, intended only for the named recipient(s) and may contain information that is privileged or exempt from disclosure under applicable law. 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