Histopathology

The Histopathology Request Form

All specimens are to be accompanied by barcode labels (CPOE- Computerised Physician Order Entry system).

Quickguide Doctor CPOE HistoCyto - OT.pdf

Quickguide CPOE HistoCyto - Clinic_Ward.pdf

Information entered into the CPOE system must include:

• Patient's name, NRIC number, visit account number, age and sex
• Hospital, department and ward number, or name of clinic
• Clinical Diagnosis
• Clinical summary/ procedure
• Nature of specimen, anatomical site, and date and time specimen taken
• Name of consultant-in-charge, doctor performing procedure and their MCR number

The following are also useful information:

• Operative findings
• Treatment rendered
• Provisional diagnoses
• Previous biopsy number or date of previous operation, if any
• Additional tests required

Submit one electronic order for the same patient at the same operation, irrespective of the number of specimens. Make sure "Specimen Label Completed" and "Vetted & Order form completed (Dr Only)" are ticked before despatching specimens.

Additional tests ordered (immunohistochemistry, molecular, FISH or special stain), after a case has been reported, are to be accompanied by a hardcopy Histopathology request or CPOE order. The request form must include:

• Patient's name, NRIC number, visit account number, age, date of birth and sex
• Hospital, department and ward number, or name of clinic
• Name of consultant-in-charge, doctor performing procedure and their MCR numbers
• Any additional important information not previously presented

Criteria for Unacceptable Samples

The laboratory cannot process the specimen if the request form is incompletely filled or if data are discrepant. This will result in delay of the turnaround time for the histopathology report.
 

Examples of criteria for Unacceptable Samples

Insufficient Specimen – Insufficient specimen to perform analysis.

Specimen Leaked – Container improperly secured.

Specimen Leaked – Broken Container.

Mislabelled – Serial number on specimen and request form do not correspond.

Mislabelled – Name/NRIC no. on specimen and request form do not correspond.

Mislabelled – Test(s) requested on specimen and request form discordant.

Mislabelled – Incomplete patient data.

Mislabelled – No Label on specimen and/or request form.

Mislabelled – Request form/ specimen label incomplete or illegible.

Specimen Problem – Wrong/ unsuitable sent.

Specimen Problem – Specimen not taken/ Swab stick seal not broken/ empty container.

Specimen Problem – Swab dried out/ no transport media used.

Specimen Problem – Specimen without request form/ Request form without specimen.

Specimen Problem – Specimen sent is not suitable for the test(s) requested.

Specimen Problem – Unsuitable specimen.

Miscellaneous Reasons – Test not offered by SGH laboratories.

Miscellaneous Reasons – Test cancelled

Specimens for amendments should not be sent through the porter with effect from Sep 2017. This is to mitigate any loss of specimen. Telephone/ email to inform the respective department/ ordering clinician to rectify the discrepancy on site at the laboratory. Histology orders requiring amendment will be rejected for documentation and a new histology order should be made. Staff making correction on site is to fill up the "Collected/ Amended By" section.

Name of Staff nurse, location, telephone number, technologist rejecting and reason sent to EMR.

Collection through Central porter/ Transport services/ E-porter

1. The ward/ department inform the Lab staff over the phone that they will be using central porter/ transport services/ E-porter to collect the rejected requests and specimen.
2. Lab staff to ask for a verbal agreement from the ward/ department that the porter collecting the specimen is authorized to collect the rejection request on their behalf.
3. When the staff arrives for collection, they are to fill up the "Collected By" section of the rejection form. The authorization section at the bottom of the rejection form is then filled up by the Processing I/C with the necessary details of the ward/ department staff and the porter.

EQA

Histopathology

Operating Hours

Office Hours

The operating hours of the Histopathology Specimen Reception are:

Routine/non-emergency and stat/emergency tests should be requested during office hours whenever possible. Stat/emergency tests are those the results of which are needed for immediate treatment and management of the patients. They are performed as soon as the samples reach the relevant laboratories. Please do not send non-emergency samples collected after office hours or on weekends as emergency requests, but instead send them on the following weekday.

Histopathology

Introduction

Surgical, anatomical and consultative pathology services are available through pathologists in the Division of Pathology. The services available include:

1. Routine surgical biopsies
2. Frozen section service / Mohs surgery
3. Specialised biopsies (e.g. renal biopsies, bone marrow trephine biopsies, gastrointestinal biopsies, liver biopsies)
4. Immunofluorescence for renal and skin cases
5. Immunohistochemistry
6. Electron microscopy
7. Tissue preparation for Polymerase Chain Reaction (PCR)/Molecular
8. Autopsy service
9. Tissue for crystal detection (preferably without fixative)

Special instructions on Specimen Handling

• Specimens are to be sent in clean leak proof containers placed within sealed bags or double sealed leak proof bags completely immersed in 10% buffered neutral formalin. 

• Lymph nodes and samples requiring additional tests such as PCR and Fluorescence in situ hybridisation (FISH) are to be fixed in formalin as well. Specimens for immunofluorescence microscopy are to be sent fresh without fixative to the laboratory immediately to prevent drying up of tissues. Specimens for electron microscopy are fixed in 2.5% glutaldehyde.
• Label each container or bag with the correct corresponding electronic barcode label.
• Specimens requiring urgent reporting should be labelled 'URGENT' at 'Special Instruction' and dispatched immediately.
• Specimens should be delivered in its entirety without any removal of parts thereof without the approval of the pathologist.
• There should be one specimen per container appropriately labelled with correct corresponding electronic barcode label.
• Multiple small specimens, such as gastrointestinal biopsies, should be mounted on a piece of filter paper and properly labelled.  In the CPOE system, clear indication should be made as to where the specimens are taken from.
• Large specimens such as small and large bowel resection are to be cut opened with faecal contents removed prior to dispatch.  The specimens should be immersed in 10% buffered neutral formalin.
• For specimens where orientation is important, mark or tag the specimen and resection margins with sutures. Indicate this information in the CPOE system.
• Do not force a large specimen into a smaller container.  Large specimen must be completely immersed in formalin for proper fixation.
• Do not crush specimens with forceps, hemostats or other instruments.  Avoid extensive cautery when possible.
• Cold ischemia time should be indicated in the CPOE order under "Routine> Site & Nature of Specimen". E.g. 1) BREAST LUMP LEFT [Spec Out : 17:20:00][Spec Fix : 17:25:00]
• For submission of prepared blocks/slides, please securely submitted blocks/slides in a container labeled with two identifiers, if blocks/slides only contain one identifier.
• All specimens are collected in their respective centres for collective delivery to the Histopathology Laboratory.
• Specimens for routine histopathology examination are delivered by porter from the respective departments to the Histopathology Laboratory.
• DO NOT DISPATCH SPECIMENS VIA THE PNEUMATIC TUBE SYSTEM (PTS). Staff at Histopathology laboratory will acknowledge receipt of specimens by signing the dispatch list that accompanies the specimens.

Routine Biopsy Specimens

Specimens submitted for routine histology are categorised as indicated below, with a separate charge for each category. Multiple charges apply for multiple containers submitted.

Specimen Categories

Specialised Investigations

Note: The assays used for clinical reporting have undergone robust in-house optimisation and/or validation and are used with appropriate quality assurance and quality control measures in line with laboratory best practice and accreditation. Most are registered for in-vitro diagnostic use ( IVD), a small minority may not be formally registered or used "off-label'.

Type of Examination and Their Submission Requirements

Frozen Section

1. The circulating nurse places the specimen for frozen section examination into a properly labelled container without preservative. Specimens from different sites requiring separate diagnosis should be placed in individual containers and labelled appropriately.
2. The operating room number and telephone number must be included in the CPOE system.
3. The attending pathologist is stationed at the Frozen Section room in the operating theatre suite from 8.30 am to 5 pm from Monday to Friday. Tel No. 6321 3530/3763.
4. For exceptional request for Frozen Section support on Saturday morning, the requesting surgeon will have to make special arrangement with the pathologist-on-call the day before. Alternatively, in special circumstances after office hours, the on-call technologist and pathologist can be reached by phone.
5. The specimen with correct CPOE order information and the frozen section dispatch book must be submitted to the attending pathologist stationed at the Frozen Section room. Acknowledgement of receipt of specimens will be made by signing the dispatch book.
6. Once the result is ready, the pathologist will either call the operating room for the report to be collected or deliver the report personally.
7. The report will then be filed in the case notes if no further investigation is required.
8. Additional specimens obtained for routine histology from the same patient are dispatched according to "Special instructions on Specimen Handling".

Liver Biopsies

1. Place in container with 10% buffered formalin.
2. Label containers and complete Histo CPOE order.

Muscle and Nerve Biopsies

    1.  Notify the lab at least TWO days in advance of procedure. The following persons are to be notified: 

      a. Chua Huimin, Medical Laboratory Scientist: (HP) +65-93638905 email: chua.hui.min@sgh.com.sg

      b. Lee Ming, Consultant Pathologist: (HP) +65-81257461 email: lee.ming@singhealth.ccom.sg 

   2. Procedure for obtaining and sending biopsies:

1. A surgeon familiar with the procedure should perform the muscle biopsy.
2. Technical pointers: Ideally, two strips of muscle approximately 2 cm x 0.5 cm are obtained. The long axis of the specimens should parallel to the direction of the muscle fibers. Where possible, aim for the belly and avoid myotendinous junctions. A muscle that is moderately but not severely affected should be used for the biopsy. Prior discussion with the neurologist is helpful. Avoid using muscle that has been probed with an EMG needle. Avoid electrocautery completely when opening muscle and harvesting the specimen. If using local anaesthetic, ensure the muscle is not directly injected.
3. Ideally, schedule the biopsy early in the morning so that specimen arrives at the Pathology Laboratory before 12 noon.
4. It is preferable that the specimen be delivered fresh STAT or within one hour after excision. Wrap the muscle in a piece of saline-moistened gauze (moistened, not soaking wet) and place it in a container or plastic bag. DO NOT IMMERSE BIOPSY SAMPLES IN  NORMAL SALINE. Send immediately to:                                        

   Specimen Reception,
   Department of Anatomical Pathology, 
   Level 10 Diagnostics Tower,
   Academia                                                                                                                                                                                                                                                                                                           

5. If biopsy done outside SGH campus and specimen will take more than 1 hour but less than 3 hours to arrive, use the method in 'd', but transport the specimen in a cooler box filled with ordinary ice. ENSURE THAT THE MUSCLE DOES NOT COME INTO DIRECT CONTACT WITH THE ICE.

Endoscopic Biopsies and Prosate Core Biopsies

These have different charges depending on the number of specimens.

1. Gastrointestinal biopsies are best orientated so that the plane of sectioning is perpendicular to the mucosal surface. Whenever possible, endoscopic biopsies of the gastrointestinal tract should be mounted on to a piece of filter paper, numbered and put immediately into fixative.
2. The anatomical sites of the biopsies should be clearly entered into CPOE order and the specimens similarly numbered on the strip of filter paper.
3. Preferably, biopsies from different anatomical sites e.g. stomach, ascending colon, transverse colon etc, should be placed in separate containers.

Surgically Resected Gastrointestinal Specimens, e.g. Colon, Stomach

1. The specimen should be opened and the contents cleaned out.
2. Immerse the entire specimen in 10% buffered formalin. The volume of 10% buffered neutral formalin should be at least 10 times the volume of the specimen as recommended  by the College of American Pathologists. Make sure that the entire specimen is submerged completely in formalin.

Renal Biopsies

1. Label containers and complete Histo CPOE order.
2. Renal biopsies are subjected to examination by light microscopy, electron microscopy and immunofluorescence. After the biopsy is done, samples must be divided carefully using a sharp blade to avoid crush artefact. A dissecting microscope is helpful in identifying tissue with glomeruli. The pieces of tissue are to be placed as quickly as possible into suitable containers with appropriate fixatives as indicated:

   a) Light microscopy – modified Bouin's fluid (Dubossey fixative)

   b) Electron microscopy – 2.5% glutaraldehyde in cacodylate buffer (the time for which the tissue is placed into fixative must be recorded)

   c) Immunofluorescence – Fresh tissue is required. Specimen is wrapped in aluminum foil, placed in a cryotube and delivered to the lab on ice. Contact the laboratory (Tel: 6321 4008) for further information, if necessary.

Testicular Biopsies

1. Submit specimens in Bouin's fluid. It may be necessary to contact the laboratory (Tel: 6321 4008) for the necessary fixative.
2. Label containers and complete Histo CPOE order.

Bone Marrow Trephine Biopsies

1. Specimens should be placed in 10% buffered formalin.
2. Label containers and complete Histo CPOE order.

Immunohistochemistry

Please raise a CPOE histopathology request with the following information or please fill up a histopathology request form with the following information:

a. Patient's name, NRIC number, sex, age, date of birth

b. Clinical diagnosis, relevant clinical information

c. Specimen type:

1. 1. For SGH specimens please provide Biopsy number/Or nature of specimen and when the specimen was taken
   2. For external material: Please arrange for material to be sent to SGH Histolab

d. Name of consultant-in-charge with MCR number, clinic, telephone/fax number

e. Test required

f. Please ensure that all compulsory fields in CPOE are filled up and the relevant boxes are ticked "Y" before saving and sending the CPOE order.

g. Print the CPOE labels and send to SGH Histolab via e-porter (labels only)

Immunofluorescence

Fresh tissue is required. Specimen is wrapped in aluminium foil, placed in a cryotube and delivered to the lab on ice. Contact the laboratory (Tel: 63214008) for further information, if necessary.

Electron Microscopy

Specimen is placed in 2.5% glutaraldehyde in cacodylate buffer (the time for which the tissue is placed into fixative must be recorded).

Contact the laboratory (Tel: 6321 4008) for further information, if necessary.

Tissue Preparation for Polymerase Chain Reaction (PCR)/Molecular Studies

1. Refer to Immunohistochemistry (above) for creating CPOE order.
2. Requirements for external materials for Molecular test:

   a) A paraffin block with adequate tumour content (refer to sample requirements  below for tumour content requirement for each test)

   b) If unable to provide a paraffin block, please provide unstained sections required for the test. Refer to sample requirement below for more information.

   c) For FISH tests on paraffin sections, please refer to cytogenetics lab for requirements and turnaround time.

3. For requests from external institutions, please raise a memo with the same information as above in point 1 and a copy of pathology report. Please indicate the billing location.
4. Upon receiving or retrieving of sample, Histopathology lab takes 4-5 working days to submit the sample to the respective laboratory for testing. Please check with the respective laboratory (Molecular lab, ATOM lab, Cytogenetic lab and Central TB lab) for turnaround time of individual test performed by them.

Sample requirements:

Contact laboratory (Tel: 6321 4956) for further information.

Autopsy Service

Contact pathologist-on-duty (Tel: 6321 4008) for information on procedure.

Specimen Collection Services

SGH Operating Theatres

By Operating Theatre porters: 9.00 am & 3.00 pm (Monday – Friday) / 9.00 am only (Saturday)

Do not despatch specimens via the Pneumatic Tube System (PTS).

SGH Specialist Outpatient Clinics, Endoscopy Centre, Wards and Diagnostic Xray

The porters from these departments will deliver the specimens to the laboratory.

Do not despatch specimens via the Pneumatic Tube System (PTS).

Non-SGH sources

Send specimens to 
            20 College Road
            Academia
            Level 10, Diagnostic Tower
            Singapore 169856
Please call Tel: 6326 6632 or 63214008.

Turnaround Time

These are variable according to the nature of the specimen received and the complexity of specialized tests that are required if necessary.  The approximate turn-around time from time of receipt to time of reporting is as follow:

An inadequately-filled histopathology order will result in delay of turnaround time.

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