Automation In Histology Advances and Improvements in Procedures, Methods, and Equipment for the Hist

1
Automation In Histology Advances and
Improvements in Procedures, Methods, and
Equipment for the Histology At Massachusetts
General Hospital

• James Happel, DLM (ASCP) HTL
• Technical Director of Surgical Pathology
• Research and Development

2
Disclaimer

• This presentation is NOT intended to be the
• do all, end all
• only way to skin a cat
• we know how to do it and you dont
• all-knowing, all-seeing
• omnipotent, authoritative directive on histology.

3
Disclaimer (continued)

• This presentation IS intended to be a
• this is the way we do things
• theres more than one way to skin a cat
• many people have asked how we do things at
  Massachusetts General Hospital so we thought wed
  put together a Power Point for the APIII
  Conference in Pittsburgh this year
• presentation.

4
Disclaimer (continued)

• Therefore
• You will hear the names and models of specific
  instruments and equipment used at MGH.
• We are not advocating for any product/manufacturer
  , these are simply the instruments/reagents/method
  s we found work best for us.

5
Outline
6
Outline

• MGH By The Numbers

7
Outline

• MGH By The Numbers
• Where Are We Now?

8
Outline

• MGH By The Numbers
• Where Are We Now?
• Instruments and Processes

9
Outline

• MGH By The Numbers
• Where Are We Now?
• Instruments and Processes
• Life At Massachusetts General Hospital Pathology

10
Outline

• MGH By The Numbers
• Where Are We Now?
• Instruments and Processes
• Life At Massachusetts General Hospital Pathology
• Lets Take A Tour

11
Outline

• MGH By The Numbers
• Where Are We Now?
• Instruments and Processes
• Life At Massachusetts General Hospital Pathology
• Lets Take A Tour
• Questions

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MGH Department of Pathology by the Numbers
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MGH Department of Pathology by the Numbers

• 800 Employees AP and CP

16
MGH Department of Pathology by the Numbers

• 800 Employees AP and CP
• Histology/Surgical Pathology Laboratory 54
  Employees

17
MGH Department of Pathology by the Numbers

• 800 Employees AP and CP
• Histology/Surgical Pathology Laboratory 54
  Employees
• 26 in Histology Lab Proper (19 Histology
  Technicians and Technologists)

18
MGH Department of Pathology by the Numbers

• 800 Employees AP and CP
• Histology/Surgical Pathology Laboratory 54
  Employees
• 26 in Histology Lab Proper (19 Histology
  Technicians and Technologists)
• 6 in Back Bench Accessioning (1 Laboratory
  Aide)

19
MGH Department of Pathology by the Numbers

• 800 Employees AP and CP
• Histology/Surgical Pathology Laboratory 54
  Employees
• 26 in Histology Lab Proper (19 Histology
  Technicians and Technologists)
• 6 in Back Bench Accessioning (1 Laboratory
  Aide)
• 2 Supervisors

20
MGH Department of Pathology by the Numbers

• 800 Employees AP and CP
• Histology/Surgical Pathology Laboratory 54
  Employees
• 26 in Histology Lab Proper (19 Histology
  Technicians and Technologists)
• 6 in Back Bench Accessioning (1 Laboratory
  Aide)
• 2 Supervisors
• 5 Pathologists Assistants

21
MGH Department of Pathology by the Numbers

• 800 Employees AP and CP
• Histology/Surgical Pathology Laboratory 54
  Employees
• 26 in Histology Lab Proper (19 Histology
  Technicians and Technologists)
• 6 in Back Bench Accessioning (1 Laboratory
  Aide)
• 2 Supervisors
• 5 Pathologists Assistants
• 3 Grossing Technicians

22
MGH Department of Pathology by the Numbers

• 800 Employees AP and CP
• Histology/Surgical Pathology Laboratory 54
  Employees
• 26 in Histology Lab Proper (19 Histology
  Technicians and Technologists)
• 6 in Back Bench Accessioning (1 Laboratory
  Aide)
• 2 Supervisors
• 5 Pathologists Assistants
• 3 Grossing Technicians
• 5 Transcriptionists

23
MGH Department of Pathology by the Numbers

• 800 Employees AP and CP
• Histology/Surgical Pathology Laboratory 54
  Employees
• 26 in Histology Lab Proper (19 Histology
  Technicians and Technologists)
• 6 in Back Bench Accessioning (1 Laboratory
  Aide)
• 2 Supervisors
• 5 Pathologists Assistants
• 3 Grossing Technicians
• 5 Transcriptionists
• 5 Immunohistochemistry Technologists

24
MGH Department of Pathology by the Numbers

• 800 Employees AP and CP
• Histology/Surgical Pathology Laboratory 54
  Employees
• 26 in Histology Lab Proper (19 Histology
  Technicians and Technologists)
• 6 in Back Bench Accessioning (1 Laboratory
  Aide)
• 2 Supervisors
• 5 Pathologists Assistants
• 3 Grossing Technicians
• 5 Transcriptionists
• 5 Immunohistochemistry Technologists
• 2 Autopsy Dieners

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MGH Department of Pathology by the Numbers

• Approx. 78,000 Surgical Cases/Year

26
MGH Department of Pathology by the Numbers

• Approx. 78,000 Surgical Cases/Year
• 900 - 1,200 Blocks/Day Average

27
MGH Department of Pathology by the Numbers

• Approx. 78,000 Surgical Cases/Year
• 900 - 1,200 Blocks/Day Average
• 2,000 HE Slides/Day Average

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MGH Department of Pathology by the Numbers

• Approx. 78,000 Surgical Cases/Year
• 900 - 1,200 Blocks/Day Average
• 2,000 HE Slides/Day Average
• 350 Immunohistochemistry Slides/Day

29
MGH Department of Pathology by the Numbers

• Approx. 78,000 Surgical Cases/Year
• 900 - 1,200 Blocks/Day Average
• 2,000 HE Slides/Day Average
• 350 Immunohistochemistry Slides/Day
• 480 Autopsies/Year

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MGH Department of Pathology by the Numbers

• 80 Attending Pathologists
• 40 Residents and 10 Fellows

• Obstetrics and Gynecology
• Bone and Soft Tissue
• Gastroenterology
• Hematopathology
• Neurology

• Dermatology
• Clinical Pathology
• Nephrology
• Cytology
• Breast Pathology

• Infectious Disease
• E.N.T.
• Pulmonology
• Cardiovascular

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October 16, 1846 Ether Dome
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October 16, 1846 Ether Dome The first
successful demonstration of ether
anesthesia
35
Where Are We Now?
36
What is Histology?
The ideal function of the technique of
pathological histology is to fix tissues for
microscopic examination that every tissue-element
or pathological product is perfectly preserved
with all its morphological and chemical
properties intact.

Pathological Technique
Frank Burr Mallory, A.M., M.D. and
James Homer Wright, A.M., M.D.


1904
37
Histology

• Autopsy
• Cytology
• Microbiology
• Immunopathology
• - Immunohistochemistry
• - In-Situ Hybridization
• - Cytochemistry
• - Flow Cytometry/Immunofluorescence

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Work Flow Processes

• Receipt and Accession of Specimen
• Labeling of requisition and specimen container
• Printing of Cassettes
• Prosection of Specimen
• Specimen Processing (Histology Laboratory)
• Printing of Labels For Glass Slides
• Slide/Case Delivery To Pathologist
• Read and Sign Out
• Slide and Block Storage and Retention

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Histological Processes

• Tissue Processing
• Embedding
• Microtomy
• Slide drying
• Hematoxylin and Eosin Staining
• Coverslipping

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Tissue Processing

• The Basics

• Fixation

41
Tissue Processing

• The Basics

• Fixation
• Dehydration

42
Tissue Processing

• The Basics

• Fixation
• Dehydration
• Clearing

43
Tissue Processing

• The Basics

• Fixation
• Dehydration
• Clearing
• Infiltration

44
Tissue Processing

• The Basics

• Formalin

45
Tissue Processing

• The Basics

• Formalin
• Alcohol

46
Tissue Processing

• The Basics

• Formalin
• Alcohol
• Xylene (Chloroform)

47
Tissue Processing

• The Basics

• Formalin
• Alcohol
• Xylene (Chloroform)
• Paraffin

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Tissue Processing Times
1904
2004
__________________________________________________
____________________

• 95 alcohol 6 hours 1. 70 alcohol 1 hour
• 100 alcohol 6 hours 2. 95 alcohol 1 hour
• Chloroform 6 hours 3. 95 alcohol 1 hour
• Chloroform w/paraffin 3 hours 4. 100
  alcohol 1 hour
• Paraffin bath x 2 2 hours 5. 100 alcohol 1
  hour
• Embed and cool quickly 6. 100 alcohol 1
  hour
• in cold water 7. xylene ¾ hour
• 8. xylene 1 hour
• 9. xylene 1 hour
• 10. paraffin 1 hour
• 11. paraffin 1 hour
• 12. paraffin 1 hour
• Total Processing Time 23 hours Total
  Processing Time 11 ¾ hours

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Tissue Processing Times
1904
2004
__________________________________________________
____________________

• 95 alcohol 6 hours 1. 70 alcohol 1 hour
• 100 alcohol 6 hours 2. 95 alcohol 1 hour
• Chloroform 6 hours 3. 95 alcohol 1 hour
• Chloroform w/paraffin 3 hours 4. 100
  alcohol 1 hour
• Paraffin bath x 2 2 hours 5. 100 alcohol 1
  hour
• Embed and cool quickly 6. 100 alcohol 1
  hour
• in cold water 7. xylene ¾ hour
• 8. xylene 1 hour
• 9. xylene 1 hour
• 10. paraffin 1 hour
• 11. paraffin 1 hour
• 12. paraffin 1 hour
• Total Processing Time 23 hours Total
  Processing Time 11 ¾ hours

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Throughput of Specimens

• Tissue cassettes are batched together in
  baskets/racks
• Approximately 150 180 cassettes per rack
• Multiple racks per processing run
• 150 540 cassettes per run
• Processing time from 8 to 11 ¾ hours

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Tissue Processors
The Autotechnicon
Ol Ironside
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Microm STP 420D
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Vision BioSystems (VBS) Peloris
54
Leica Microsystems ASP 300S
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Tissue Tek VIP 5
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Histological Processes

• Tissue Processing
• Embedding
• Microtomy
• Slide drying
• Hematoxylin and Eosin Staining
• Coverslipping

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Embedding

• - Embedding is the placing of
  processed tissue specimens
  into metal mold bases of liquid paraffin in
  preparation for microtomy

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Embedding
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Microm EC 350
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EMS Tissuepro 150
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Tissue Tek Tec 5
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Histological Processes

• Tissue Processing
• Embedding
• Microtomy
• Slide drying
• Hematoxylin and Eosin Staining
• Coverslipping

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Microtomy and Slide Drying

• Microtomy is the sectioning of paraffin embedded
  tissue specimen blocks. Routine sections cut at
  4 microns
• Slide Drying is the heating of slides to melt
  paraffin from tissue in preparation for staining
  

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Microtomy and Slide Drying
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Microtomy
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Histological Processes

• Tissue Processing
• Embedding
• Microtomy
• Slide drying
• Hematoxylin and Eosin Staining
• Coverslipping

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Hematoxylin and Eosin Staining

• Hematoxylin and eosin are the life-blood of the
  histology laboratory
• In 2007 the MGH histology laboratory produced
  approximately 400,000 slides

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Hematoxylin and Eosin Staining
1904
2004

• 1. Hematein or its ammonia salt 1
  gram 1. Order pre-made hematoxylin
  in gallon
• 2. 90 alcohol
  50 c.c. container.
• 3. Alum 50 grams
  2. Filter and use
• 4. Water
  1,000 c.c.
• 5. Thymol
  a crystal
• Dissolve the hematein or its ammonia salt in the
• alcohol by the aid if heat, and add it to the
  alum
• dissolved in the water. The solution can be
• diluted with 20 parts or water or of weak alum
• solution
• Mallory and Wright
• Pathological Technique

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Hematoxylin and Eosin Staining
1904
2004

• 1. Stain 3 to 5 minutes or longer in 1.
  Xylene 3 minutes
• hematoxylin 2. 100 ETOH 30 seconds
• 2. Wash out in 1 alum solution until 3.
  95 ETOH 15 seconds
• the stain is precise 4. Running
  water 15 seconds
• 3. Wash thoroughly in several changes of 5.
  Hematoxylin 5 minutes
• water 6. Running water 15 seconds
• 4. Alcohol, 95 7. Running water 1 minute
• 5. Stain paraffin sections in a 5 to 10 8.
  Acid alcohol 45 seconds
• aqueous solution of eosin for 20
  minutes 9. Running water 15 seconds
• or longer 10. Ammonia water 5 seconds
• 6. Wash in water 11. Running water 2 minutes
• 7. Wash out a little in 90 alcohol 12. 95
  ETOH 15 seconds
• 8. Dehydrate in absolute alcohol 13. Eosin 45
  seconds
• 9. Xylol 14. 100 ETOH 30 seconds
• 10. Canada Balsam 15. 100 ETOH 30 seconds
• 16. Xylene 30 seconds
• 
  17.
  Xylene 30 seconds
• 18. Xylene 30 seconds

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Hematoxylin and Eosin Staining
1904
2004

• 1. Stain 3 to 5 minutes or longer in 1.
  Xylene 3 minutes
• hematoxylin 2. 100 ETOH 30 seconds
• 2. Wash out in 1 alum solution until 3.
  95 ETOH 15 seconds
• the stain is precise 4. Running
  water 15 seconds
• 3. Wash thoroughly in several changes of 5.
  Hematoxylin 5 minutes
• water 6. Running water 15 seconds
• 4. Alcohol, 95 7. Running water 1 minute
• 5. Stain paraffin sections in a 5 to 10 8.
  Acid alcohol 45 seconds
• aqueous solution of eosin for 20
  minutes 9. Running water 15 seconds
• or longer 10. Ammonia water 5 seconds
• 6. Wash in water 11. Running water 2 minutes
• 7. Wash out a little in 90 alcohol 12. 95
  ETOH 15 seconds
• 8. Dehydrate in absolute alcohol 13. Eosin 45
  seconds
• 9. Xylol 14. 100 ETOH 30 seconds
• 10. Canada Balsam 15. 100 ETOH 30 seconds
• 16. Xylene 30 seconds
• 
  17.
  Xylene 30 seconds
• 18. Xylene 30 seconds

71
Hematoxylin and Eosin Staining
1904
2004

• 1. Stain 3 to 5 minutes or longer in 1.
  Xylene 3 minutes
• hematoxylin 2. 100 ETOH 30 seconds
• 2. Wash out in 1 alum solution until 3.
  95 ETOH 15 seconds
• the stain is precise 4. Running
  water 15 seconds
• 3. Wash thoroughly in several changes of 5.
  Hematoxylin 5 minutes
• water 6. Running water 15 seconds
• 4. Alcohol, 95 7. Running water 1 minute
• 5. Stain paraffin sections in a 5 to 10 8.
  Acid alcohol 45 seconds
• aqueous solution of eosin for 20
  minutes 9. Running water 15 seconds
• or longer 10. Ammonia water 5 seconds
• 6. Wash in water 11. Running water 2 minutes
• 7. Wash out a little in 90 alcohol 12. 95
  ETOH 15 seconds
• 8. Dehydrate in absolute alcohol 13. Eosin 45
  seconds
• 9. Xylol 14. 100 ETOH 30 seconds
• 10. Canada Balsam 15. 100 ETOH 30 seconds
• 16. Xylene 30 seconds
• 17. Xylene 30 seconds
• 18. Xylene 30 seconds

Total Staining Time 55 Minutes
Total Staining Time 18 Minutes
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Hematoxylin and Eosin Staining
1904
2004

• 1. Stain 3 to 5 minutes or longer in 1.
  Xylene 3 minutes
• hematoxylin 2. 100 ETOH 30 seconds
• 2. Wash out in 1 alum solution until 3.
  95 ETOH 15 seconds
• the stain is precise 4. Running
  water 15 seconds
• 3. Wash thoroughly in several changes of 5.
  Hematoxylin 5 minutes
• water 6. Running water 15 seconds
• 4. Alcohol, 95 7. Running water 1 minute
• 5. Stain paraffin sections in a 5 to 10 8.
  Acid alcohol 45 seconds
• aqueous solution of eosin for 20
  minutes 9. Running water 15 seconds
• or longer 10. Ammonia water 5 seconds
• 6. Wash in water 11. Running water 2 minutes
• 7. Wash out a little in 90 alcohol 12. 95
  ETOH 15 seconds
• 8. Dehydrate in absolute alcohol 13. Eosin 45
  seconds
• 9. Xylol 14. 100 ETOH 30 seconds
• 10. Canada Balsam 15. 100 ETOH 30 seconds
• 16. Xylene 30 seconds
• 
  17. Xylene 30 seconds
• 18. Xylene 30 seconds

Total Staining Time 55 Minutes
Total Staining Time 18 Minutes
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Hematoxylin and Eosin Staining
74
Thermo Scientific Shandon Varistain Gemini ES
75
Leica XL Slide Stainer
76
Leica ST4040 Linear Stainer
77
Histological Processes

• Tissue Processing
• Embedding
• Microtomy
• Slide drying
• Hematoxylin and Eosin Staining
• Coverslipping

78
Coverslipping
79
Leica CV 5030 Coverslipper
80
Tissue Tek Glas Coverslipper
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Tissue Tek Primsa and Film
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Microwave Processing
84
Microwave Processing

• Uses precise microwave energy to process tissue
  specimens
• Utilizes standard processing reagents formalin,
  alcohol, xylene and paraffin
• Allows for continuous throughput of specimens

85
Microwave Processing
Routine Processing
Routine processing uses formalin, alcohol, xylene
and paraffin for specimens sectioned to a
thickness of up to 5 mm Reprocessing is performed
using the same programmed times as routine
processing
Vs.
Features
Number of
Cassettes 150
Histoprocessing time
Specimen thickness
180 minutes
needle biopsies
240 480 minutes
lt 3 mm
480 660 minutes
lt 5 mm
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Microwave Processing
Routine Processing
Routine processing uses formalin, alcohol, xylene
and paraffin for specimens sectioned to a
thickness of up to 5 mm Reprocessing is performed
using the same programmed times as routine
processing
Features
Number of
Cassettes 150
Histoprocessing time
Specimen thickness
180 minutes
needle biopsies
240 480 minutes
lt 3 mm
480 660 minutes
lt 5 mm
87
Microwave Processing
Routine Processing
Routine processing uses formalin, alcohol, xylene
and paraffin for specimens sectioned to a
thickness of up to 5 mm Reprocessing is performed
using the same programmed times as routine
processing
Features
Number of
Cassettes 150
Histoprocessing time
Specimen thickness
180 minutes
needle biopsies
240 480 minutes
lt 3 mm
480 660 minutes
lt 5 mm
88
Microwave Processing
Routine Processing
Routine processing uses formalin, alcohol, xylene
and paraffin for specimens sectioned to a
thickness of up to 5 mm Reprocessing is performed
using the same programmed times as routine
processing
Features
Number of
Cassettes 150
Histoprocessing time
Specimen thickness
180 minutes
needle biopsies
240 480 minutes
lt 3 mm
480 660 minutes
lt 5 mm
89
Microwave Processing
Routine Processing
Routine processing uses formalin, alcohol, xylene
and paraffin for specimens sectioned to a
thickness of up to 5 mm Reprocessing is performed
using the same programmed times as routine
processing
Features
Number of
Cassettes 150
Histoprocessing time
Specimen thickness
180 minutes
needle biopsies
240 480 minutes
lt 3 mm
480 660 minutes
lt 5 mm
90
Microwave Processing
Routine Processing
Routine processing uses formalin, alcohol, xylene
and paraffin for specimens sectioned to a
thickness of up to 5 mm Reprocessing is performed
using the same programmed times as routine
processing
Features
Number of
Cassettes 150
Histoprocessing time
Specimen thickness
180 minutes
needle biopsies
240 480 minutes
lt 3 mm
480 660 minutes
lt 5 mm
91
Microwave Processing
Routine Processing
Routine processing uses formalin, alcohol, xylene
and paraffin for specimens sectioned to a
thickness of up to 5 mm Reprocessing is performed
using the same programmed times as routine
processing
Features
Number of
Cassettes 150
Histoprocessing time
Specimen thickness
180 minutes
needle biopsies
240 480 minutes
lt 3 mm
480 660 minutes
lt 5 mm
92
Microwave Processing
Routine Processing
Routine processing uses formalin, alcohol, xylene
and paraffin for specimens sectioned to a
thickness of up to 5 mm Reprocessing is performed
using the same programmed times as routine
processing
Features
Number of
Cassettes 150
Histoprocessing time
Specimen thickness
180 minutes
needle biopsies
240 480 minutes
lt 3 mm
480 660 minutes
lt 5 mm
93
Microwave Processing
Routine Processing
Routine processing uses formalin, alcohol, xylene
and paraffin for specimens sectioned to a
thickness of up to 5 mm Reprocessing is performed
using the same programmed times as routine
processing
Features
Number of
Cassettes 150
Histoprocessing time
Specimen thickness
180 minutes
needle biopsies
240 480 minutes
lt 3 mm
480 660 minutes
lt 5 mm
94
Microwave Processing
Routine Processing
Routine processing uses formalin, alcohol, xylene
and paraffin for specimens sectioned to a
thickness of up to 5 mm Reprocessing is performed
using the same programmed times as routine
processing
Features
Number of
Cassettes 150
Histoprocessing time
Specimen thickness
180 minutes
needle biopsies
240 480 minutes
lt 3 mm
480 660 minutes
lt 5 mm
95
Microwave Processing
Routine Processing
Routine processing uses formalin, alcohol, xylene
and paraffin for specimens sectioned to a
thickness of up to 5 mm Reprocessing is performed
using the same programmed times as routine
processing
Features
Number of
Cassettes 150
Histoprocessing time
Specimen thickness
180 minutes
needle biopsies
240 480 minutes
lt 3 mm
480 660 minutes
lt 5 mm
96
Microwave Processing

• Microwave systems allow for continuous
  throughput
• Less flexibility due to greater specificity of
  function

97
Keys to Microwave Processing
98
Keys to Microwave Processing
99
Keys to Microwave Processing
100
Keys to Microwave Processing
101
Keys to Microwave Processing
102
Keys to Microwave Processing
103
Pelco BioWave Pro
104
Milestone Pathos Microwave Processor
105
Hacker MARS Microwave Histoprocessor
106
Rapid Processing
107
Rapid Processing
- Reduces processing time from 8 11 ¾ hours to
2.5 6 hours
108
Rapid Processing
- Reduces processing time from 8 11 ¾ hours to
2.5 6 hours - Rapid processing utilizes
methanol, ethanol and isopropanol No clearing
agents (xylene) used. This procedure does have a
tendency to dry out (albeit slightly) smaller
biopsies due the abundant alcohol.
109
Rapid Processing/Microwave
110
Rapid Processing/Microwave
Sakura Fineteks Tissue-Tek Xpress
111
Rapid Processing/Microwave
Sakura Fineteks Tissue-Tek Xpress
112
Rapid Processing/Microwave
Sakura Fineteks Tissue-Tek Xpress
113
Rapid Processing/Microwave
114
Rapid Processing/Microwave
115
Rapid Processing/Microwave
116
Rapid Processing/Microwave
117
Rapid Processing/Microwave
118
Rapid Processing/Microwave
- Allows for continuous throughput of specimens
119
Embedding
120
Embedding
121
Tissue Tek Paraform Sectionable Cassette System
122
Tissue Tek Paraform Sectionable Cassette System
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Tissue Tek Paraform Sectionable Cassette System
Sakura Fineteks Tissue-Tek Autotek
- Continuous throughput of specimens
129
Tissue Tek Paraform Sectionable Cassette System
- Continuous throughput of specimens
130
Hematoxylin and Eosin Staining
- Ready to use Hematoxylin and Eosin Staining
System
SurgiPath Selec Tech
131
Hematoxylin and Eosin Staining
- High Definition HE
Ventana Medical Systems, Inc.
132
Hematoxylin and Eosin Staining
- Ventana Medcial systems, Inc.

• Symphony One Touch HE

133
Hematoxylin and Eosin Staining

• Modular system xylene free
• Slides input directly from waterbath
• Dries, stains and coverslips slide with bar
  coded label
• Continuous throughput

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Life At Massachusetts General Hospital Pathology
136
Life At Massachusetts General Hospital Pathology

• Life at MGHs surgical pathology laboratory
  starts with our Laboratory Information System

137
Life At Massachusetts General Hospital Pathology

• Several years ago, MGH began using the Tamtron
  PowerPath LIS

138
Life At Massachusetts General Hospital Pathology

• Several years ago, MGH began using the Tamtron
  PowerPath LIS
• Dr. Ulysses Balis started tinkering with
  PowerPath to customize it for use in the MGH
  surgical pathology laboratory

139
Life At Massachusetts General Hospital Pathology

• Several years ago, MGH began using the Tamtron
  PowerPath LIS
• Dr. Ulysses Balis started tinkering with
  PowerPath to customize it for use in the MGH
  surgical pathology laboratory
• Dr. Balis created AP Middleware

140
Life At Massachusetts General Hospital Pathology

• Several years ago, MGH began using the Tamtron
  PowerPath LIS
• Dr. Ulysses Balis started tinkering with
  PowerPath to customize it for use in the MGH
  surgical pathology laboratory
• Dr. Balis created AP Middleware
• The finished product is known today as
  PowerPaths AMP Module

141
Life At Massachusetts General Hospital Pathology

• Using the LEAN principles of
• Just in time supply
• Right person right job
• Work flow continuity up-stream processes in
  direct proximity to down-stream processes

142
Histology LEAN Project
143
Life At Massachusetts General Hospital Pathology

• Lets take a tour

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Life At Massachusetts General Hospital Pathology

• Accessioning

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OR Window
Specimen Accessioning
Specimen Accessioning
Specimen Accessioning
Cassetting
Telepathology Scope
Cryo
Scope
FS
Scope
Scope
FS
Saw Room
PA
Photography
PA
Cryo
Storage
HE Staining
Storage
Lung CV
Storage
Storage
ENT
GIL
BRST
BST
GU
GYL
OB
148

OR Window
Specimen Accessioning
Specimen Accessioning
Specimen Accessioning
Cassetting
Telepathology Scope
Cryo
Scope
FS
Scope
Scope
FS
Saw Room
PA
Photography
PA
Cryo
Storage
HE Staining
Storage
Lung CV
Storage
Storage
ENT
GIL
BRST
BST
GU
GYL
OB
149

OR Window
Specimen Accessioning
Specimen Accessioning
Specimen Accessioning
Cassetting
Telepathology Scope
Cryo
Scope
FS
Scope
Scope
FS
Saw Room
PA
Photography
PA
Cryo
Storage
HE Staining
Storage
Lung CV
Storage
Storage
ENT
GIL
BRST

BST
GU
GYL
OB
150

OR Window
Specimen Accessioning
Specimen Accessioning
Specimen Accessioning
Cassetting
Telepathology Scope
Cryo
Scope
FS
Scope
Scope
FS
Saw Room
PA
Photography
PA
Cryo
Storage
HE Staining
Storage
Lung CV
Storage
Storage
ENT
GIL
BRST

BST
GU
GYL
OB
151

OR Window
Specimen Accessioning
Specimen Accessioning
Specimen Accessioning
Cassetting
Telepathology Scope
Cryo
Scope
FS
Scope
Scope
FS
Saw Room
PA
Photography
PA
Cryo
Storage
HE Staining
Storage
Lung CV
Storage
Storage
ENT
GIL
BRST

BST
GU
GYL
OB
152

OR Window
Specimen Accessioning
Specimen Accessioning
Specimen Accessioning
Cassetting
Telepathology Scope
Cryo
Scope
FS
Scope
Scope
FS
Saw Room
PA
Photography
PA
Cryo
Storage
HE Staining
Storage
Lung CV
Storage
Storage
ENT
GIL
BRST

BST
GU
GYL
OB
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OR Window
Specimen Accessioning
Specimen Accessioning
Specimen Accessioning
Cassetting
Telepathology Scope
Cryo
Scope
30 seconds to walk
FS
Scope
Scope
FS
Saw Room
PA
Photography
PA
Cryo
Storage
HE Staining
Lung CV
Storage
Storage
Storage
ENT
GIL
BRST

BST
GU
GYL
OB
154

OR Window
Specimen Accessioning
Specimen Accessioning
Specimen Accessioning
Cassetting
Telepathology Scope
Cryo
Scope
Between 250 to 300 cases/day
FS
Scope
Scope
FS
Saw Room
PA
Photography
PA
Cryo
Storage
HE Staining
Lung CV
Storage
Storage
Storage
ENT
GIL
BRST

BST
GU
GYL
OB
155

OR Window
Specimen Accessioning
Specimen Accessioning
Specimen Accessioning
Cassetting
Telepathology Scope
Cryo
Scope
Just over 2 hours/day walking across the lab
FS
Scope
Scope
FS
Saw Room
PA
Photography
PA
Cryo
Storage
HE Staining
Lung CV
Storage
Storage
Storage
ENT
GIL
BRST

BST
GU
GYL
OB
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Specimen Accessioning
Specimen Accessioning

Specimen Accessioning
Cassetting
Telepathology Scope
Cryo
Scope
FS
Scope
Scope
FS
Saw Room
PA
Photography
PA
Cryo
Storage
HE Staining
Storage
Lung CV
Storage
Storage
ENT
GIL
BRST
BST
GU
GYL
OB
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POWERPATH Cassette LabelGeneral Data Laser
Printed
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OR Window
Specimen Accessioning
Specimen Accessioning
Specimen Accessioning
Cassetting
Telepathology Scope
Cryo
Scope
FS
Scope
Scope
FS
Saw Room
PA
Photography
PA

Cryo
Storage
HE Staining
Storage
Lung CV
Storage
Storage
ENT
GIL
BRST
BST
GU
GYL
OB
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Small Grossing Technicians
Storage
Tech 2
Tech 1
Cassetting
Storage
Supervisors Office
Supervisors Office
Tech 4
Tech 3
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Storage
7
Embedding
6
5
8 Tissue Processors
4
MW
3
2
1
My Office
Pod 1
HE Stainers
Cover Slippers
Pod 2
Embed
and
Pod 3
Embed
Pod 4
Block and Slide Reconciliation
Slide Checkout
Special Stains
Storage
Immuno Cutting
Neuro Path
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Storage
7
Embedding
6
5
8 Tissue Processors
4
MW
3
2
1
My Office
Pod 1
HE Stainers
Cover Slippers
Pod 2
Embed
and
Pod 3
Embed
Pod 4
Block and Slide Reconciliation
Slide Checkout
Special Stains
Storage
Immuno Cutting
Neuro Path
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Whats Being Worked On At MGH?
219
Automated Microtomy
220
Automated Microtomy

• Kurabo Industries, LTD. Osaka, Japan developing
  the AS-200 Research application

221
High voltage power supply for positive
charge
Carrier tape
Slide glass
Adhering solution
Peltier-Element (Cooling)
Electrode
Heating (Stretching)
Tissue block
Blade
Humidification
Humidification
Condensation
Heating (stretching and drying)
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Sections Cut From AS-200
223
Thicker-gtDarker
9um
2um
224
Whole Slide Imaging (WSI)
225
Whole Slide Imaging (WSI)

• The area of tissue is ltlt than the area of the
  slide
• A low resolution, wide angle camera takes an
  snapshot of the entire slide
• Proprietary algorithms use that image identify
  the area that is tissue (as opposed to glass,
  dirt and other artifacts)
• The system will then only image the areas of
  tissue

Dirt
Edge of cover slip
S06-1000 A 2 1 HE Patrick Patient

Tissue
226
Whole Slide Imaging (WSI)

• Tissue Finding Algorithms
• Tissue finding can significantly increase capture
  speed by limiting the amount of area the needs to
  captured
• But tissue finding is difficult and potentially
  catastrophic if an area of tissue is not
  identified

Dirt
Edge of cover slip
S06-1000 A 2 1 HE Patrick Patient

Tissue
227
Whole Slide Imaging (WSI)

• Pre-focusing
• High speed system do not stop and focus at each
  new tile
• Using the low resolution, wide field image, the
  system choses 10 80 points
• They perform traditional auto-focusing on those
  areas
• The system then knows exactly what the working
  distance needs to be to be in focus at those
  points

228
Whole Slide Imaging (WSI)

• Pre-focusing
• During image capture, the objective lens flies
  along the estimated focus surface above the slide
  within the area identified as tissue
• As the camera flies, it captures tiles or
  strips that are then knitted together to form
  the complete whole slide image
• A precise stage and precise communication between
  the stage and the camera is the key in making
  this work

S06-1000 A 2 1 HE Patrick Patient

Estimate Focus Surface
Focus Point Tissue Focus Point
229
A Slightly Different Approach
Array Microscopy
230
A Slightly Different Approach

• Rather than using a single lens to view an image
  on a slide, use 80 lenses to view the same area.

VS
231
A Slightly Different Approach
Used with permission from Michael R. Descour,
Ph.D., President , DMetrix
232
A Slightly Different Approach
Used with permission from Michael R. Descour,
Ph.D., President , DMetrix
233
Multi-Spectral Imaging
234
Multi-Spectral Imaging

• Components of a tissue section transmit and
  absorb light at a variety of different
  wavelengths. This pattern is specific for each
  individual component.
• In multi-spectral imaging, images are taken at
  discrete wavelengths and identify tissue
  components by the way those specific wavelengths
  are absorbed (or transmitted) A fingerprint,
  so to speak.

235
Multi-Spectral Imaging
Glass Slide
Tissue
Camera
Light Source
Server
16 Band Filter
236
Multi-Spectral Imaging

• What does this enable us to do?

237
Multi-Spectral Imaging

• What does this enable us to do?
• Virtual Slide Staining

238
Digital Adjustment
239
Digital Adjustment
240
Digital Adjustment
241
Digital Adjustment
242
Digital Adjustment
243
Digital Adjustment
244
Digital Adjustment
245
Digital Adjustment
246
Digital Adjustment
247
Physical HE Stain
248
Physical HE Stain
Digital Trichrome Stain From HE stain
249
Physical Trichrome Stain
Digital Trichrome Stain From HE stain
250
Specimen Discard

• Using the PowerPath LIS
• Time of Case Sign Out is Recorded
• 14 Days After Sign Out Bar Code Labeled Are
  Scanned
• If the Specimen Can Be Discarded

251
Specimen Discard
252
Specimen Discard

• Using the PowerPath LIS
• Time of Case Sign Out is Recorded
• 14 Days After Sign Out Bar Code Labeled Are
  Scanned
• If the Specimen Can Be Discarded
• If the Specimen Should Not Be Discarded

253
Specimen Discard
254
Whats Next?
255
Whats Next?

• Radiofrequency Identification (RFID)

256
Whats Next?

• Radiofrequency Identification (RFID)
• Telepathology

257
Whats Next?

• Radiofrequency Identification (RFID)
• Telepathology
• Digital Slide Imaging - Whole Slide Imaging

258
Whats Next?

• Radiofrequency Identification (RFID)
• Telepathology
• Digital Slide Imaging - Whole Slide Imaging
• Virtual Slide Staining

259
Whats Next?

• Radiofrequency Identification (RFID)
• Telepathology
• Digital Slide Imaging - Whole Slide Imaging
• Virtual Slide Staining
• Completely Automated Histology Laboratories

260
Lots and Lots of Data on Every Slide
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Special Thanks to John Gilbertson Yukako
Yagi Ulysses Balis Bruce Hamaty David
Wilbur Anand Dighe Michael Descour Andrew
Rosenberg Steve Conley Michelle Lee Walter Van
Tilburg Jim Bacho Babiker Bedri Paul Weber
263
Questions?
Thank You James Happel