The application of a microwave technique for the preparation of cell blocks from sputum

Making a science out of preanalytics: An analytical method to determine optimal tissue fixation in real-time

Modern histopathology is built on the cornerstone principle of tissue fixation, however there are currently no analytical methods of detecting fixation and as a result, in clinical practice fixation is highly variable and a persistent source of error. We have previously shown that immersion in cold formalin followed by heated formalin is beneficial for preservation of histomorphology and have combined two-temperature fixation with ultra-sensitive acoustic monitoring technology that can actively detect formalin diffusing into a tissue. Here we expand on our previous work by developing a predictive statistical model to determine when a tissue is properly diffused based on the real-time acoustic signal. We trained the model based on the morphology and characteristic diffusion curves of 30 tonsil cores. To test our model, a set of 87 different tonsil samples were fixed with four different protocols: dynamic fixation according to our predictive algorithm (C/H:Dynamic, N = 18), gold-standard 24 hour room temperature (RT:24hr, N = 24), 6 hours in cold formalin followed by 1 hour in heated formalin (C/H:6+1, N = 21), and 2 hours in cold formalin followed by 1 hour in heated formalin (C/H:2+1, N = 24). Digital pathology analysis revealed that the C/H:Dynamic samples had FOXP3 staining that was spatially uniform and statistically equivalent to RT:24hr and C/H:6+1 fixation protocols. For comparison, the intentionally underfixed C/H:2+1 samples had significantly suppressed FOXP3 staining (p<0.002). Furthermore, our dynamic fixation protocol produced bcl-2 staining concordant with standard fixation techniques. The dynamically fixed samples were on average only submerged in cold formalin for 4.2 hours, representing a significant workflow improvement. We have successfully demonstrated a first-of-its-kind analytical method to assess the quality of fixation in real-time and have confirmed its performance with quantitative analysis of downstream staining. This innovative technology could be used to ensure high-quality and standardized staining as part of an expedited and fully documented preanalytical workflow.

Comparison of the quality of the microwave cell-block method with the conventional cell-block method in processing body fluid samples

INTRODUCTION

Conventional cell blocks (CCB) prepared from cytological specimens are very useful but the method is relatively time-consuming. Suitable modifications in cell-block techniques are beneficial for improving the turnaround time. We share our experience of a rapid microwave cell-block (MCB) technique.

AIM AND OBJECTIVES

To study the quality of routine and immunohistochemical (IHC) staining of cell-block sections from serous body fluids prepared by the MCB technique compared with the CCB technique.

METHOD

A total of 177 serous body fluid samples were processed by routine centrifugation technique, and the sediments were used for cell-block preparations by both conventional and rapid microwave methods. Cell-block sections were stained with haematoxylin and eosin stain. Haematoxylin and eosin staining quality was analysed using three parameters (cellularity, morphology and staining intensity). IHC for epithelial membrane antigen and calretinin were also performed, and the quality of staining was evaluated on 62/177 samples. Results were analysed using appropriate statistical tests.

RESULTS

The time taken for processing cell blocks by the MCB method was 1 hour and 18 minutes compared to 13 hours and 45 minutes by CCB. The quality of sections by both methods showed good agreement for cellularity and intensity of staining, and moderate agreement for morphology. A 100% concordance was noted for distinguishing benign and malignant samples on morphology as well as with IHC stain results.

CONCLUSION

Although the techniques are comparable in terms of quality of routine and IHC staining, we recommend using the MCB technique due to its short turnaround time.

Cell blocks in cytopathology: a review of preparative methods, utility in diagnosis and role in ancillary studies

The cell block (CB) is a routine procedure in cytopathology that has gained importance because of its pivotal role in diagnosis and ancillary studies. There is no precise review in the published literature that deals with the various methods of preparation of CB, its utility in diagnosis, immunocytochemistry (ICC) or molecular testing, and its drawbacks. An extensive literature search on CB in cytology using internet search engines was performed for this review employing the following keywords: cell block, cytoblock, cytology, cytopathology, methods, preparation, fixatives, diagnostic yield, ancillary and molecular studies. Ever since its introduction more than a century ago, the CB technique has undergone numerous modifications to improve the quality of the procedure; however, the overall principle remains the same in each method. CBs can be prepared from virtually all varieties of cytological samples. In today's era of personalized medicine, cytological specimens, including CBs, augment the utility of cytological samples in analysing the molecular alterations as effectively as surgical biopsies or resection specimens. With the availability of molecular targeted therapy for many cancers, a large number of recent studies have used cytological material or CBs for molecular characterization. The various techniques of CB preparation with different fixatives, their advantages and limitations, and issues of diagnostic yield are discussed in this review.

Comparison of clarity of nucleocytoplasmic differentiation of oral tissues processed by microwave and conventional methods

The microwave-assisted tissue processing is believed to have brought a revolutionary improvement in histopathology. The technique shortens the tissue processing time from hours to minutes. The technique is responsive to the patient and physician needs, improves the use of reagents while reducing or eliminating their toxicity, creates a personnel-friendly workflow, and places the laboratory in a better position to meet the demands of the rapidly expanding field of molecular medicine. This study was conducted to determine the efficacy of microwave tissue processing method for orofacial biopsy specimens by comparing 5 different protocols of microwave histoprocessing with the conventional method, based on the clarity of nucleocytoplasmic differentiation of tissues processed by each method. The current study demonstrated that different protocols of microwave histoprocessing can be achieved without a demonstrable decrease in section quality or interpretation.

Theory and practice of combining coagulant fixation and microwave histoprocessing

The German, F. Blum, introduced formalin as a fixative in 1893. Formalin rapidly became popular for hardening and preserving gross human and animal specimens. As a result, microscopy for diagnostic pathology by combining paraffin embedding and formalin fixation was developed. Alcohol-based fixatives have coagulation of proteins as their main preservative effect. Because there is no cross-linking, immunostaining is not compromised, and DNA and RNA is not damaged. Ethyl alcohol was used by Dutch scientists of the 18th century, but was replaced by the cheaper formalin. Addition of low molecular weight polyethylene glycol (PEG) optimized the coagulant fixative, Kryofix. The polyethylene glycol prevents excessive hardening and enhances the speed of coagulation of proteins. Kryofix was used on a large scale for skin biopsies in Leiden between 1987 and 2001. DNA preservation by the formulated coagulant fixative, BoonFix, is related to the concentration of ethyl alcohol, PEG and acetic acid. BoonFix has been used since 2004 in Leiden for over 40,000 diagnostic skin biopsies and more than 100,000 cervical samples. A literature review and three decades of experience with coagulant, formalin-free fixatives in pathology suggest that when health authorities realize that formalin invalidates expensive tests, it might eventually be eliminated legislatively from diagnostic pathology. Finally, coagulant fixation is optimal for microwave histoprocessing where ethyl alcohol is followed by isopropanol.

Double staining of skeleton using microwave irradiation

The fetal skeleton double staining method is used to reveal developmental abnormalities in the skeletal system. We used alizarin red S and alcian blue successfully with microwave irradiation for skeletal double staining. The fixation time was reduced from 4-7 days to 2-2.5 min and the staining time was reduced from 4 days to 23 min.

Microwave fixation of whole fetal specimens

This study compares microwave fixation of whole fetal specimens with conventional techniques performed at room temperature. All fetuses were obtained from the same pregnant rat; half of them were placed in neutral formalin for 15 min at room temperature, then irradiated for 2.5 min in a domestic microwave oven. The remaining fetuses were placed in neutral formalin at room temperature for 48 hr as a control. Both experimental and control groups were exposed to routine tissue processing for light microscopy and embedded in paraffin wax. Sections 5 microns thick were stained with hematoxylin and eosin. Our results showed that the microwave technique reduced the fixation time while providing thin sections that were equal to or better in quality than those in the control group.

Microwaves for immunohistochemistry

Microwaves are now widely used in immunohistochemistry for fixing and stabilizing tissue prior to embedding and cutting, for antigen retrieval and for immunoincubations. These techniques can be used for frozen sections and for material embedded in paraffin and plastic. Material prepared in this way shows high contrast in light microscopy. In principle, these microwave methods can also be used for electron microscopy. To be successful in the application of these techniques, insight into the physics of exposure to microwaves and the effects of microwaves on the material is a must. Microwave immunohistochemistry depends on optimal temperature control. To guarantee this, special measures should be taken and dedicated laboratory ovens should be used. The recently developed Coverplate units facilitate immunoincubations in the microwave oven. We show that the total microwave approach, combining microwave fixation, embedding and immunoincubations, is very useful for confocal microscopy.

Improving biological dyes and stains: quality testing versus standardization

This paper discusses the impact of both standardization and quality testing of dyes and stains in biology and medicine. After the brief review of why standardized dyes and strains are not presently available commercially, two types of testing and ways of improving dye quality are described. National or international organizations could be established to define standardization of dyes and stains. Standardization would be specifically defined as a list of physico-chemical parameters such as elaborated in this paper. Commercial batches of comparable quality may be labeled by the supplier as "standard dye," a procedure currently performed by the European Council for Clinical and Laboratory Standardization (ECCLS). Also recommended to improve dye quality is commercial dye testing by independent laboratories with subsequent certification for use. This sort of quality control is currently carried out in the United States by the Biological Stain Commission (BSC). The advantages and disadvantages of both techniques and the use of image analysis for the definition of standards are discussed. A combination of both the BSC testing protocols and the ECCLS standards should be established for extended quality control of biological dyes and stains.

Standardization of biological dyes and stains: pitfalls and possibilities

The present paper gives a review of the actual state of standardization of biological dyes and stains. In a first part general information is given on practical problems encountered by the routine user of dyes with special emphasis on dye contamination. Some theoretical aspects of standardization are discussed. The second part of the paper gives more detailed information on commercial batches of hematoxylin-eosin-, Giemsa- and Papanicolaou-stains and on their standardization. Special problems arising with the application of image analysis techniques are briefly mentioned. User-oriented specifications for the standardization of dyes, stains and staining procedures are given. Fluorescent dyes and dyes used in chromogenic reagents such as the Feulgen-Schiff reaction are not included in this review.

Microwaves for microscopy

Sample preparation for microscopy is based on physical and chemical processes. These processes can be influenced by microwave irradiation. The prerequisite for the development of good microwave procedures is knowledge of histochemistry combined with understanding of the physics of microwave irradiation. Examples of superior results of fixation, processing, and (immuno) staining performed in the microwave oven are presented, both for light- and electron microscopy.

Formaldehyde fixation and microwave irradiation

Formaldehyde is the most commonly used fixative in pathology laboratories. However, due to time pressures, this fixative is often not optimally exploited. The majority of biopsies are only partly fixed when histoprocessing is started, with adverse effects. This paper reports how formaldehyde fixation is improved, by using 1.5 min of microwave irradiation of tissue previously soaked for four hours in the fixation solution. It is argued that this beneficial effect of microwave irradiation can be attributed to the acceleration of the reaction of formaldehyde to the tissue. Formation of free formaldehyde, by the dehydration of methylene glycol present in the tissue when the irradiation starts, is also enhanced. Five different formaldehyde-containing fixatives were evaluated, using five different working protocols. Spleen was taken as a suitable tissue for these tests. The technique described leads to uniform microscopical results. It is a simple method and is suitable for use in routine laboratories.

Histoprocessing with the microwave oven: an update

This paper evaluates and extends the novel method of preparing tissue blocks for paraffin sections within 30 to 60 min, that was proposed in early 1985 in a paper by Boon et al. (1986). More than 2 years' additional experience and testing various microwave ovens has led to new protocols reported in this paper. Results are given of testing (i) an especially designed microwave oven for histoprocessing, (ii) microwavable reagents, (iii) processing larger numbers of specimens simultaneously, (iv) handling different types and sizes of tissue. It is concluded that effective temperature control offers substantial advantages. In addition, the possibilities of performing routine diagnostic pathology omitting formalin altogether are sketched.

Microwave fixation provides excellent preservation of tissue, cells and antigens for light and electron microscopy

It was demonstrated that microwave energy used simultaneously in combination with low concentrations of glutaraldehyde (0.05%) and formaldehyde (2.0%) rapidly preserved light microscopic histology and excellent fine structural details, as well as a variety of cytoplasmic and membrane-bound antigens. Specimen blocks up to 1 cm3 can be fixed in as brief a time as 26 ms using a specially designed microwave device (ultrafast microwave fixation method). The fast microwave fixation method, using a commercially available device, was successfully used to preserve granule-bound rat mast cell chymase which was subsequently detected by a postembedding immunogold procedure. Control of the following parameters is important to the microwave fixation method: (1) specimens with one dimension less than 1 cm; (2) irradiation temperatures lower than 50 degrees C; (3) irradiation times less than 50 s; (4) immediate replacement of the postirradiation solution with cold storage buffer; (5) fixing the specimen within 15 min after it is removed from its blood supply.

Microwave irradiation of human brain tissue: production of microscopic slides within one day

A three step method using microwave irradiation enabled microscopic slides of human brain tissue to be obtained within one working day: steps 1 and 2 hardened and solidified brain tissue; step 3 completed formalin fixation. The efficacy and precision of the method was compared with slides of conventionally processed brain tissue that had been fixed in formalin for six weeks. The microscopic quality of the sections was excellent with good presentation of brain tissue and equalled that of conventionally processed slides.

The microwave Rio-Hortega technique: a 24 hour method

Application of microwaves in histochemistry and cytochemistry generally speeds up the technique. Microwaves stimulate diffusion into the tissue and influence the proteins and membrane of the cell. Silver impregnation techniques for the brain, such as the fast Rio-Hortega or the slow Golgi-Cox technique, normally require a minimum time period of 7 days and 20 days respectively. Using microwaves, the Rio-Hortega technique can be completed within 24 h. In sections prepared from mature brains, good silver impregnation of cell bodies, of axons and their terminals, and of dendrites and their spines are obtained. An explanation is given as to why the method cannot be further reduced in time. To our knowledge, this is the first report of the application of microwave irradiation for colouring pieces of tissue.