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1216
material being stained, the xative being used and most importantly, the avidity of the haematoxylin solution. An average dierentiation time is from 2–6 s.
4. Wash in water, followed by the bicarbonate solution for 10–20 s. It neutralizes all the acid.
5. Rinse in water.
6. Stain with eosin for 10–20 s.
7. Rinse in water, dehydrate (take through increasing concentrations of alcohol).
8. Clear and mount as desired.
Medical Laboratory Technology: Volume 3
Grunwald-Giemsa Staining (GGS)
Some laboratories prefer Romanowsky-type stains for examination of ne needle aspiration and serous uid smears. Nuclear detail, the nucleoli in particular, is well delineated but experience is still needed for accurate cell determination. With serous uids, adenocarcinoma cells are distinguishable, especially if any intracytoplasmic vacuolation is present. For best results, smears should always be air dried, followed by xation in methanol for 5–10 min.
Reagents
• May–Grunwald solution
Stock solution: Grind 0.3 g of the powdered May–Grunwald dye in a lile amount of
methanol.
Decant and then add more methanol continuing to grind until the dye is in solution for
a nal volume of l00 mL; lter.
Working solution: Dilute 20 parts of May–Grunwald solution with 30 parts of pH 6.8
phosphate buer.
• Giemsa solution
Stock solution: Giemsa powder 1 g Glycerine 66 mL Absolute methyl alcohol 66 mL Mix Giemsa powder and glycerine, and place in a 60°C oven for 30 min to 2 h. Add 66
mL of absolute methyl alcohol.
Working solution: Stock Giemsa solution 50 drops Distilled water 50 mL Prepare solution at the time of use. Do not reuse.
Procedure
1. Fix the smear by routine procedure.
2. Stain the xed smears in diluted May–Grunwald solution for 10 min.
3. Rinse in pH 6.8 buer (close to neutral).
4. Stain in the diluted Giemsa solution for 30 min.
5. Wash and dierentiate in pH 6.8 buer for 5–20 min until the desired color balance is achieved.
6. Allow smears to dry and mount in a DPX-type mount.
Results
Nuclei: Purple Cell cytoplasm: Blue to mauve Red blood cells: Pink
Laboratory Techniques in Diagnostic Exfoliative Cytology
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Other Staining Procedures
Several other staining procedures, described in staining tissue sections, are also used in exfoliative cytological investigations. These include periodic acid-Schi (PAS), silver stain method and Feulgen reaction.
Periodic Acid-Schiff (PAS) stain kit
Intended use
The commercially available Periodic Acid-Schi (PAS) stain kit is used for staining bone marrow and blood cell smear.
Principle
Periodic Acid-Schi reaction (PAS) oxidizes Ethylene Glycol (—CHOH—CHOH) which is contained in glycogen polysaccharides of cells, to turn into dialdehyde (—CHO—CHO). Subsequently, aldehyde will react with colorless Fucshin to form a red-fuchsin compound in cytoplasm.
Contents of the kit
1. Fixative (solution A)
2. Periodic Acid Solution (solution B)
3. Schi's reagent (solution C): Keep in brown bole. Cap tightly. Long exposure in the air shall cause emission of SO2 and solution will easily turn red to be denatured. Schi staining is suggested to be carried out at room temperature.
4. Hematoxylin (solution D)
Procedure
1. Dry the smear before subjecting to staining.
2. Fix smear in solution A for 30 s
3. Rinse with distilled water.
4. Air dry or dry with absorbent paper.
5. Drop solution B (PAS acid solution) on slide to fully cover the smear for 5 min.
6. Rinse with distilled water.
7. Dry with lter paper or dry in the air.
8. Drop solution C on slide to fully cover the smear for 10–15 min.
9. Rinse with distilled water for 5 min.
10. Counterstain with solution D for 1–2 min.
11. Rinse with distilled water.
12. Dry the smear for microscopic examination.
Expected results
Red (or purple) granules found in cytoplasm means positive. Interpretation may vary with dierent kinds of cells in specimen.
Special note
1. PAS stain can be used in old but well-preserved smear and smear stained with Wright’s stain. However, smear stained with Wright’s stain should be decolorized with ethanol before performing PAS staining.
2. Microscopic examination should be performed immediately aer PAS staining, since positive reaction will turn weaker aer one week.
3. Always read the instruction given in the kit as insert.
4. Do not use the reagents beyond the stated expiration date.
5. Wastes should be disposed with care as biohazardous materials by following local EPA guidelines.
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Medical Laboratory Technology: Volume 3
Methenamine silver–Grocott’s modified stain
(Available as kit)
Purpose
To identify fungi
Principle
The mucopolysaccharide components of the fungal cell wall are oxidized to release aldehyde groups. The aldehyde groups then react with the silver nitrate, reducing it to metallic silver, rendering them visible.
Control: Any tissue containing fungus. A control block made-up from tissue containing aspergillosis and Pneumocystis is preferred.
Fixative: 10% formalin Technique: Cut paran sections 4–5 mm.
Equipment
• Acid cleaned glassware
• Coplinjars
• Microwave oven
Reagents (available in kit)
1. 2% Chromic Acid:
• Chromium trioxide 10 g • Distilled water 500 mL
Solution is stable for 6 months. Caution Corrosive acid, possible carcinogen, avoid
contact and inhalation.
2. 1% Sodium metabisulphite:
Sodium metabisulphite 5 g Distilled water 500 mL Solution is stable for 6 months.
3. 5% Borax:
Sodium borate 5 g Distilled water 100 mL Solution is stable for 3 months.
4. Methenamine Silver Stock Solution:
3% Methenamine (hexamethylenetetramine) 100 mL 5% Silver nitrate 5 mL Mix, pour into an acid-cleaned brown bole. Store in a refrigerator. Solution is stable for
3 months. Caution Corrosive, possible carcinogen.
5. 0.5% Gold Chloride:
Gold chloride 0.5 g Distilled water 100 mL
Store in acid cleaned bole, refrigerate. Stable for 1 year. Caution Avoid contact and
inhalation.
6. 0.2% Light green:
Light green SF yellow 0.2 g Distilled water 100 mL Glacial acetic acid 0.2 mL
Mix. Stable for 6 months. Caution Avoid contact and inhalation.
Laboratory Techniques in Diagnostic Exfoliative Cytology
Safety: All chemicals are potentially dangerous and carcinogenic.
Procedure
Following is a general procedure which can be modied for cytological specimens.
1. Deparanize and hydrate with distilled water (dip through decreasing concentrations of alcohol).
2. *Stain with 2% Chromic acid, microwave Hi power for 45 s, and allow it to stand for 5 min.
3. Wash in tap water, rinse in distilled water.
4. Stain with 1% sodium metabisulphite and leave for 1 min at room temperature.
5. Wash in tap water, rinse in distilled water (3 changes).
6. *Stain with working methenamine silver solution, microwave Hi power for 70 s. Tissue should be the color of a brown paper bag. Agitate the slides in hot solution.
7. Rinse in distilled water (2 changes).
8. Stain with 0.5% gold chloride. Leave for 1 min or until gray.
9. Wash in distilled water.
10. Stain with 5% hypo and leave for 3 min.
11. Wash in tap water, rinse in distilled water.
12. Working light green, 1 min.
13. Rinse in distilled water.
14. Dehydrate, clear, and put coverslip.
* Conventional Method
5% chromic acid, 60°C water bath for 1 h.
Silver solution, 60°C water bath for 1 h or until brown.
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Feulgen reaction
Kits are available in the market. It takes about 1 h and 5 min to perform the test. Stability— one year when stored in a refrigerator (2–8°C).
Purpose
This product is for the preparation of cyto-histological samples for optical microscopy.
Application demonstration of DNA in tissue sections (and cytological specimens).
Principle
The method is divided into two parts:
Acid hydrolysis (5N HCl, ambient temperature, 40 min), designed to separate
selectively 2 purine bases, namely adenine and guanine, from DNA molecule.
Staining of apurinic acid resulting from hydrolysis with Schi reagent. This reagent
can be used since free deoxyribose changes to aldehyde in acid environment.
Feulgen reaction is highly selective for DNA. In fact, RNA does not react because the presence of a hydroxyl on carbon 2 of ribose prevents HCl from hydrolysing sugar. Moreover, this reaction allows a very precise localization of DNA since, aer purine bases have been removed, deoxyribose radicals are bound to phosphoric acid of apurinic acid macromolecule.
Reagents
A. Hydrochloric acid solution 5N 30 mL B. Schi Reagent according to Feulgen 30 mL C. Sodium thiosulphate solution 30 mL D. Fixative solution 30 mL
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Procedure
1. Bring section to distilled water.
2. Put on the section, 10 drops of reagent A; leave to act 40 min.
3. Double washing in distilled water.
4. Put on the section, 10 drops of reagent B; leave to act 10 min.
5. Drain the slide without washing and put on the section, 10 drops of reagent C; leave to act 2 min.
6. Drain the slide without washing and put on the section, 10 drops of reagent D; leave to act 3 min.
7. Wash in running tap water for 5 min.
8. Dehydrate through ascending alcohols; clear in xylene and mount.
Results
Magenta red: DNA
Warning and precaution: The product must be used exclusively by specialized technical operators. The product is classied as hazardous. Read the instructions of the manufacturer very carefully before using the product.
Storage: Store the preparation at 2–8°C. Keep the containers tightly closed.
Stability: Aer the rst opening, the product is usable until the expiry date, if correctly stored.
Disposal of hazardous preparation: Observe all state and local environmental regulations
regarding waste disposal.
Medical Laboratory Technology: Volume 3
IdEntIfyIng charactErIstIcs of BEnIgn and malIgnant cElls
Although the technician is not responsible for evaluating the stained smears, he/she should be able to dierentiate between normal and abnormal cells. This knowledge enables the evaluation of specimen preparation for microscopic examination and if not satisfactory, the process can be repeated. Additionally, an experienced technician can participate in the pre-screening of the slides and draw the aention of the cytopathologist to abnormal slides. Nonetheless, the limited training received by the technician restricts his/ her ability to identify the types of malignant cells. The evaluation by the cytopathologist is essential.
Normal and Malignant Cells
Epithelial cells line skin epidermis and the surface layer of mucous and serous membranes. The presence of various types of epithelial cells in the specimens submied for exfoliative cytology is considered normal. The epithelial cells may or may not be nucleated, depending on the stage of development. In some normal specimens, reticuloendothelial cells and macrophages may also be present. Epithelial malignant tumors (carcinomas) exhibit changes in the cellular structure of the exfoliated cells, including abnormalities in nuclear structure (increased diameter with dense chromatin) and increased nucleus. Cytoplasm ratio is one of the most important criteria of abnormal malignant cells. This is comparable to the presence of blast cells in circulating blood in patients with leukemia. Another criterion that may identify the presence of malignant cells is their grouping. Epithelial cells oen remain in groups, closely aached to each other. This adhesiveness decreases in malignant tumour cells, appearing as single cells or loosely aached groups of cells.
Laboratory Techniques in Diagnostic Exfoliative Cytology
1221
rEvIEw quEstIons
1. Discuss the clinical signicance of cytological investigation.
2. What are the most commonly submied specimens for the study of exfoliative cytology?
3. How are the specimens prepared for microscopic examination?
4. What is the most commonly used xative for cytological studies?
5. What is a Pap smear? Describe the technique.
6. List some of the identifying characteristics of malignant cells.
7. What is the most commonly used xative for cytological specimens?
8. What is the dierence between Schaudinn’s uid and Carnoy’s uid? Discuss the advantages of each of these xatives.
9. How are watery specimens concentrated prior to their microscopic observations?
10. How are cytological specimens mailed to the reference laboratories?
Basics of
39
Immuno histochemistry
Evolution of Tissue/Cellular Level Diagnostics
To begin with initial diagnosticians studied body uids and aspirates (cytology) which were easy to obtain, subsequently it ascended to tissue diagnostics (histopathology). However, with further advances it advanced to the molecular level with simultaneous interplay of immunology at a molecular level (immunohistochemistry).
Introduction
The IHC technique is a combination of immunologic and chemical reactions visualised with a photonic microscope. Immunohistochemistry (IHC) is used in histology to detect the presence of specic protein markers that can assist with accurate tumour classication and diagnosis. Immunohistochemistry has evolved to complement the Hematoxylin & Eosin (H&E) and special stain techniques that typically show tissue morphology. Where H&E and special stains are nonspecic, IHC is directed to a specic protein marker or markers. IHC is used as a diagnostic tool to assist in the diagnosis of solid tumours and cytological specimens and has been used as a primary diagnostic tool.
The technique can be divided into three phases (Table 1). Phase 1 (preanalytical) starts with sample
procurement, followed by tissue xation, processing and embedding, and ending with tissue sectioning on a microtome. Phase 2 (analytical) starts with deparafnation of tissue sections; includes preincubation steps
Table 39.1: Phases, steps and variables involved in immunohistochemistry
Phases Steps Variables
Preanalytical phase
Analytical
phase
Sample procurement Delayed fixation, prolonged ischaemia, thickness of sample Fixation Cross-linking vs coagulating fixatives, duration Decalcification Type of decalcification solution and duration Tissue processing Paraffin-embedded vs frozen tissues Tissue sectioning Thickness of tissue section, drying temperature and
duration, tissue section ageing
Deparaffinisation Dewaxing agent Antigen retrieval Detergents, enzymes, HIER Blocking nonspecific
reactivities Primary antibodies Monoclonal vs polyclonal, Ag recognition (native vs
Endogenous enzymes, hydrophobic binding, pigments
linear), specificity, species Variability
1222
Contd.
Basics of Immuno histochemistryBasics of Immuno histochemistry
Table 39.1: Phases, steps and variables involved in immunohistochemistry (Contd.)
Phases Steps Variables
Detection system Avidin-biotin vs polymer-based systems, ultrasensitive
methods
Postanalytical
phase
Enzyme-substrate­chromogen
Counter stain Contrast between chromogen and counterstain Control performance Animal species compatibility, tissue processing Interpretation Pathologist vs automated evaluation Report Percentage of positive cells, positive vs negative threshold,
Colour detection
stand-alone test vs ancillary test
Diagnostic, prognostic test
1223
(e.g. antigen retrieval, blocking of nonspecic activities), incubation with the primary antibody, and labeling of the antigen-antibody reaction; and ends with slide counterstaining and mounting of the tissue using a coverglass. Phase 3 (postanalytical) includes interpretation of results and generation of an IHC report, after the evaluation of the IHC controls.
Preanalytical Phase of IHC
Fixation
Fixation refers to the chemical and physical processes by which cells and tissues are stabilised and made ready for subsequent histopathological treatments such as slicing and staining. Fixation attenuates postmortem autolysis as well as preserves lifelike morphology and optimises macromolecules for histochemical and biochemical analyses. Fixation of tissues is necessary to (1) adequately preserve cellular components, including soluble and structural proteins; (2) prevent autolysis and displacement of cell constituents, including antigens and enzymes; (3) stabilise cellular materials against deleterious effects of subsequent procedures; and (4) facilitate conventional staining and immunostaining. Chemical xation is generally used for diagnostic IHC; the most common chemical xative is 10% neutral buffered formalin (10% NBF). Formalin not only reacts with tissue molecules, creating cross-links that anchor them in place, but also may render molecules inaccessible to antibodies used for immunohistochemical staining, a blocking process that can be reversed by antigen retrieval methods.
Decalcification
Decalcication describes the technique for removing mineral from bone or other calcied tissue so that good-quality parafn sections can be prepared that will preserve all the essential microscopic elements. Decalcication is carried out after the specimen has been thoroughly xed and prior to routine processing to parafn.
Strong acids such as hydrochloric or nitric acid at concentrations up to 10% are the most rapid in action
but if used for an excessive time will rapidly cause a loss of nuclear staining and can macerate tissues. It is important that an appropriate end-point test is used to minimise exposure of the specimens to these agents.
Weak acids such as formic acid are popular and are widely used for decalcication. Formic acid can be used as a simple 10% aqueous solution or combined with formalin or with a buffer. Although it is slower than the strong acid agents it is much gentler in action and less likely to interfere with nuclear staining. Other acids such as trichloroacetic acid (TCA) have also been used. Picric acid, as a component of some xatives has weak decalcifying properties.
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Medical Laboratory Technology: Volume 3
Chelating agents such as ethylenediaminetetra-acetic acid (EDTA), work by capturing the calcium ions from the surface of the apatite crystal, slowly reducing its size. Because the process is very slow but very gentle (weeks may be required depending on the size of the specimen), this reagent is not suitable for urgent specimens but more appropriate for research applications where very high quality morphology is required or particular molecular elements must be preserved for techniques such as IHC, FISH or PCR. It is used at a concentration of approximately 14% as a neutralised solution. The rate at which EDTA will decalcify is pH dependent. It is generally used at pH 7.0. It works more rapidly at pH 10 but some tissue elements can be damaged at alkaline pH.
If high-quality results are to be obtained it is important to determine the point at which all the calcium has been removed, because, from this point on, tissue damage seems to occur at an increasing rate. Over­decalcication, particularly with the strong acid decalciers, spoils the staining of basophilic elements such as cell nuclei and in some circumstances can cause maceration of the softer tissue elements. On the other hand specimens that are incompletely decalcied may be difcult or impossible to section.
Tissue Processing and Incubation Buffers
Once the tissue has been xed, it must be processed into a form in which it can be made into thin microscopic sections. The usual way this is done is with parafn. Tissues embedded in parafn, which is similar in density to tissue, can be sectioned at anywhere from 2 to 5 microns. The technique of getting xed tissue into parafn is called tissue processing. The main steps in this process are dehydration, clearing and impregnation. Wet xed tissues (in aqueous solutions) cannot be directly inltrated with parafn. First, the water from the tissues must be removed by dehydration process. This is usually done with a series of alcohols, say 70% to 95% to 100%. The next step is called “clearing” and consists of removal of the dehydrant with a substance that will be miscible with the embedding medium (parafn wax). The commonest clearing agent is xylene. Finally, the tissue is inltrated with the embedding agent, almost always parafn wax. The above processes are almost always automated for the large volumes of routine tissues processed. Automation consists of an instrument that moves the tissues around through the various agents on a preset time scale. Tissues that come off the tissue processor are still in the cassettes and must be manually put into the blocks by a technician who must pick the tissues out of the cassette and pour molten parafn wax over them. This “embedding” process is very important, because the tissues must be aligned, or oriented, properly in the block of parafn.
Although xation is paramount in the outcome of the antigen-antibody reaction, the incubation buffer and tissue-processing solutions can also alter antigenicity. The combination of cross-linking xatives with heat and the nonpolar solvents used in parafn embedding is thought to modify the antigen conformation so that specic epitopes may not be recognised by antibodies that would recognise those epitopes in frozen sections. Shifts in the tertiary structure of proteins (during processing) alter the structure of protein so that hydrophoebic areas are oriented outward and hydrophilic regions inward (hydrophoebic inversion) during dehydration and clearing steps, can reduce or abolish antibody binding without anigen retrieval, especially with poorly stabilised (unxed or suboptimally xed in formalin) tissues/proteins exposed to a weakly polar or nonpolar solvent. This negative effect varies with the dehydrating and clearing agent used. There is also increased background reactivity in tissues left in xylene for prolonged periods during processing.
Basics of Immuno histochemistryBasics of Immuno histochemistry
1225
Figure 39.1:
 Formaldehydexationcanalterthe3-Dstructureoftheepitopecrosslinkages;whichisreversed
byhightemperatureheating
Tissue Sectioning
The tissue sections are cut from the FFPE blocks to a desired thickness using a microtome. As a rule of thumb, the ideal thickness of the tissue should be between 2 and 4 micron for immunohistochemistry. Sectioning tissues is a real art and takes much skill and practice. Histotechnologists are the artists of the laboratory. It is important to have a properly xed and embedded block or much artifact can be introduced in the sectioning. Common artifacts include tearing, ripping, “venetian blinds”, holes, folding, etc. Once sections are cut, they are oated on a warm water bath that helps remove wrinkles. Then they are picked up on a positively charged (slides that are coated with poly-L-lysine or organosilane or APES at different concentrations) glass microscopic slide.
Adhesion of Oppositely Charged Surfaces
When immersed in an aqueous medium in the pH range 5 to 7, most tissues carry a net negative charge, owing to a small excess of acidic over basic amino acids in the structural proteins. Majority of the issues are composed largely of cellulose, which does not itself form ions but is impregnated with a variety of weak acids, and these too confer an overall negative charge. Sections of almost any tissue can therefore be expected to adhere well to a glass surface that has been treated in such a way as to make it positively charged. The modication is usually accomplished either by coating the slide with a basic polymer or by a chemical reaction that leaves amino groups linked by covalent bonds to the silicon atoms of the glass.
A frequently used basic polymer is polylysine or APES, in which every amino acid unit has an amino side chain that is quite strongly basic. Its pKa is 10.53. This is the pH at which half the amino groups are protonated. The side-chain of lysine has an unusually high pKa for an amino group and consequently polylysine is positively charged even in moderately alkaline media. Polylysine is applied to slides as an aqueous solution, which is then allowed to dry by evaporation.