We have read with interest and concern the correspondence letter published in the July issue of your journal “OSNA testing for lymph node staging in colorectal cancer”.
Although the authors state on the letter “We aim to provide unbiased data on the diagnostic accuracy of OSNA in detecting CRC nodal metastases and feedback the practicalities of running such a service in a National Health Service (NHS) cellular pathology department”, we think the information given in their article is somehow incomplete. Their conclusions are based on the analysis of 99 lymph nodes (LNs) from a small cohort of 19 cases, with only 5.2 LNs examined per patient. Current guidelines, including the guidance of The Royal College of Pathologists, recommend that at least 12 LNs should be assessed to ensure an adequate specimen evaluation and a reliable pathologic staging.[1] In contrast, several studies using colon cancer OSNA lymph node analysis have assessed 12 or more LNs.[2–4]
We agree with their statement that intraoperative OSNA detection of LN metastasis does not have a role in CRC surgery, mainly because regional lymphadenectomy is invariably included with the colectomy specimen. But this is not the target of molecular lymph node assessment in CRC. The most important clinical application of molecular LN analysis in CRC is that it enables a more precise staging in early CRC than the one obtained with conventional H&E analysis, especially useful for stage II pa...
We have read with interest and concern the correspondence letter published in the July issue of your journal “OSNA testing for lymph node staging in colorectal cancer”.
Although the authors state on the letter “We aim to provide unbiased data on the diagnostic accuracy of OSNA in detecting CRC nodal metastases and feedback the practicalities of running such a service in a National Health Service (NHS) cellular pathology department”, we think the information given in their article is somehow incomplete. Their conclusions are based on the analysis of 99 lymph nodes (LNs) from a small cohort of 19 cases, with only 5.2 LNs examined per patient. Current guidelines, including the guidance of The Royal College of Pathologists, recommend that at least 12 LNs should be assessed to ensure an adequate specimen evaluation and a reliable pathologic staging.[1] In contrast, several studies using colon cancer OSNA lymph node analysis have assessed 12 or more LNs.[2–4]
We agree with their statement that intraoperative OSNA detection of LN metastasis does not have a role in CRC surgery, mainly because regional lymphadenectomy is invariably included with the colectomy specimen. But this is not the target of molecular lymph node assessment in CRC. The most important clinical application of molecular LN analysis in CRC is that it enables a more precise staging in early CRC than the one obtained with conventional H&E analysis, especially useful for stage II patients. The OSNA assay has been validated for CRC lymph node analysis. Its sensitivity and diagnostic accuracy for LN tumor burden detection is greater than that of HE.[2,3,5] Clinicians face the problem of recurrence in up to 20% of stage II CRC patients within 5 years after a curative-intended surgical resection. They have little or no objective and reliable data for decision making on stage II CRC patients, nor can they foresee that a patient has an increased risk of disease recurrence or poor survival. In addition, several meta-analysis have demonstrated that the presence of nodal micrometastases in CRC detected by molecular methods is a prognostic factor, associated to poor survival rates.[6] Nevertheless, no survival studies have been published so far determining the amount of tumor burden detected with OSNA that has clinical significance.[3]
We have recently published three different articles addressing some of the aspects that Dr Colling and his colleagues bring up. In the first one we demonstrated that molecular positivity found in LNs by the OSNA assay correlated with other classical risk factors in CRC, such as male gender, high grade areas or signet ring cell histology.[7] Our second paper was centered on the analysis of those LNs that drain the tumor. Pre-surgical endoscopy tattoo of early CRC not only maps out the tumor LN drainage, but also enhances LN harvesting and identifies those LNs that are more prone to harbor tumor burden, detected with the OSNA assay.[8] The third paper faces one of the most important problems this letter brings up, the high cost of molecular determinations.[9] Conventional pathological LN analysis is very cheap but its sensitivity is low, since it analyzes less than 1% of the LN. It has been useful in the pre-molecular, pre-CRC-screening era. The actual scenario of early-stage CRC detection has revealed the deficiencies of the classical histology method of LN evaluation. The introduction of any method of LN analysis other than H&E results costlier, but diagnostic accuracy leads to patient’s correct management and it has an inherent prognostic information. We designed the pooling method, which allows to analyze all the LNs from CRC patients in a median of 2 determinations per case, saving 85% of time, costs and personnel. [9] With the pooling method, all LNs from the colectomy specimen are analyzed together. Combining LNs for molecular determinations solves the problem of those LNs that do not fulfill the weight criteria for single OSNA analysis. The pooling method obtains the amount of tumor burden present in the LN compartment, or total tumor load (TTL), which gives a valuable information of how much tumor has escaped from the primary tumor to the nodal compartment.
The authors also question fresh LN dissection. Fresh LN harvesting does not have to be performed immediately. It may be postponed a few hours if the colectomy specimen is kept in the refrigerator at 4ºC, immediately after surgical excision. It needs coordination between the surgical and pathology departments, accordingly to the best fitting work up at each center. The OSNA assay for CRC lymph node analysis has its indications; it is intended for early-stage CRC with high probability to have negative LNs with H&E. Exclusion criteria are fresh specimens that are received open, surgical specimens received fixed in formalin, rectal tumors treated with neoadjuvant therapy and T3 cases with extensive fat infiltration. As for T4 cases, only antimesenteric tumors could be included. As for contamination by fecal matter, the surgical specimen must be received closed. LN harvesting is performed after separation of the mesocolon fat from the colon wall. With this simple procedure, contamination should not be an issue.
The OSNA technique may force pathologists and clinicians to change their current concepts in colon cancer staging. Instead of a more precise or sharpened version of the classical pN staging, the TTL provides a continuous variable of tumor load in the nodal copartment, which may have an implicit risk of recurrence, yet to be defined with upcoming follow up data. It may enable to shift treatment decisions defined by recurrence risks obtained not only by TTL cut offs, but also from well stablished risk factors such as tumor grade, molecular profile and patient’s factors. Such an ambitious goal must be supported by ongoing studies with adequate patient data and follow up.
1 Langman G, Loughrey M, Shepherd N, et al. Association of Coloproctology of Great Britain & Ireland (ACPGBI): Guidelines for the Management of Cancer of the Colon, Rectum and Anus (2017) - Pathology Standards and Datasets. Color Dis 2017;19:74–81. doi:10.1111/codi.13708
2 Croner RS, Geppert C-I, Bader FG, et al. Molecular staging of lymph node-negative colon carcinomas by one-step nucleic acid amplification (OSNA) results in upstaging of a quarter of patients in a prospective, European, multicentre study. Br J Cancer 2014;110:2544–50. doi:10.1038/bjc.2014.170
3 Yamamoto H, Tomita N, Inomata M, et al. OSNA-Assisted Molecular Staging in Colorectal Cancer: A Prospective Multicenter Trial in Japan. Ann Surg Oncol 2015;:1–6. doi:10.1245/s10434-015-4880-x
4 Aldecoa I, Atares B, Tarragona J, et al. Molecularly determined total tumour load in lymph nodes of stage I-II colon cancer patients correlates with high-risk factors. A multicentre prospective study. Virchows Arch Published Online First: 22 July 2016. doi:10.1007/s00428-016-1990-1
5 Yamamoto H, Sekimoto M, Oya M, et al. OSNA-based novel molecular testing for lymph node metastases in colorectal cancer patients: results from a multicenter clinical performance study in Japan. Ann Surg Oncol 2011;18:1891–8. doi:10.1245/s10434-010-1539-5
6 Rahbari NN, Bork U, Motschall E, et al. Molecular detection of tumor cells in regional lymph nodes is associated with disease recurrence and poor survival in node-negative colorectal cancer: a systematic review and meta-analysis. J Clin Oncol 2012;30:60–70. doi:10.1200/JCO.2011.36.9504
7 Aldecoa I, Atares B, Tarragona J, et al. Molecularly determined total tumour load in lymph nodes of stage I–II colon cancer patients correlates with high-risk factors. A multicentre prospective study. Virchows Arch 2016;469. doi:10.1007/s00428-016-1990-1
8 Aldecoa I, Montironi C, Planell N, et al. Endoscopic tattooing of early colon carcinoma enhances detection of lymph nodes most prone to harbor tumor burden. Surg Endosc Other Interv Tech Published Online First: 2016. doi:10.1007/s00464-016-5026-3
9 Rakislova N, Montironi C, Aldecoa I, et al. Lymph node pooling: a feasible and efficient method of lymph node molecular staging in colorectal carcinoma. J Transl Med 2017;15:14. doi:10.1186/s12967-016-1114-3
I just want to put out a typo in figure (1) : the sokal score formula should be : exp(0.0116*(age - 43.4 ) + ... and not exp(0.0116*(age - 4.34 ) +... .
If you use 4.34 all you patients will be in "High Risk Group".
In a previous issue of this journal, we presented problems of using
Bouin’s fixative for immunohistochemical and nuclear morphometric assays
on prostatic biopsies(1). We agree with the important comment offered by
Berney that Bouin’s fixative could increase the sensitivity for detection
of high grade prostatic intraepithelial neoplasia (HGPIN) and prostate
cancer. Furthermore, we agree that increa...
In a previous issue of this journal, we presented problems of using
Bouin’s fixative for immunohistochemical and nuclear morphometric assays
on prostatic biopsies(1). We agree with the important comment offered by
Berney that Bouin’s fixative could increase the sensitivity for detection
of high grade prostatic intraepithelial neoplasia (HGPIN) and prostate
cancer. Furthermore, we agree that increased sensitivity could occur at
the cost of decreased specificity, as is the case for most diagnostic
assays.
Bouin’s fixation was used as a routine fixative for prostatic
biopsies at our institution owing to the better nuclear detail offered by
this fixative, making the diagnosis of HGPIN easier. Diagnosis of HGPIN
assumed greater importance in the ‘sextant biopsy era’, as men with HGPIN
had a higher chance of being diagnosed with cancer on repeat biopsies (2).
The relevance of finding HGPIN has now decreased owing to extended
prostatic biopsy sampling (3). At our institution, there has been switch
to formalin for fixing prostatic biopsies for the above two reasons —
i.e., decreased predictive value of HGPIN on biopsies, and difficulties
with various molecular assays following fixation in Bouin’s fluid. We
have noticed a decrease in the prevalence of HGPIN on biopsies following
this switch, though a formal analysis has not been performed.
The radical prostatectomy specimens at our institution continue to be
fixed with formalin, as they have always been. We agree that using a
discrepant fixative such as Bouin’s on biopsies could lead to different
patterns of agreement between biopsy and surgical specimens. It indeed
would be interesting to analyze the correlation between formalin and
Bouin’s fixed specimens to gain a better understanding of how these
fixative differences affect the likelihood of diagnosing both HGPIN and
cancer.
References
1. Ananthanarayanan V, Pins MR, Meyer RE, Gann PH.
Immunohistochemical assays in prostatic biopsies processed in Bouin's
fixative. J Clin Pathol 2005;58(3):322-4.
2. Keetch DW, Humphrey P, Stahl D, Smith DS, Catalona WJ.
Morphometric analysis and clinical followup of isolated prostatic
intraepithelial neoplasia in needle biopsy of the prostate. J Urol
1995;154(2 Pt 1):347-51.
3. Moore CK, Karikehalli S, Nazeer T, Fisher HA, Kaufman RP, Jr.,
Mian BM. Prognostic significance of high grade prostatic intraepithelial
neoplasia and atypical small acinar proliferation in the contemporary era.
J Urol 2005;173(1):70-2.
I gather from the article that an overseas graduate with an experience in Pathology can directly apply for SpR post, but the rcpath website says it is not so for histopathology. I would like to know if an overseas graduate with an experience in Pathology equivalent to the award of CCST can directly get into SpR post?
I read with interest the recent article by Biedrzycki and Baithun[1]
investigating the relationship between myocardial infarction complicated
by haemopericardium, and season. The study utilised data collected during
Coronial postmortem examinations, carried out over a 5-year period in East
London. They concluded that there was indeed a ‘seasonal variation’ for
this entity, and that the likelihood of ven...
I read with interest the recent article by Biedrzycki and Baithun[1]
investigating the relationship between myocardial infarction complicated
by haemopericardium, and season. The study utilised data collected during
Coronial postmortem examinations, carried out over a 5-year period in East
London. They concluded that there was indeed a ‘seasonal variation’ for
this entity, and that the likelihood of ventricular rupture after a
myocardial infarction is greater in ‘winter’ than ‘summer’.
It is well established that cardiac events, including arrhythmias,
myocardial infarction and sudden cardiac death are multifactorial, and
involve complex inter-relationships between anatomical or structural
elements, factors such as age and sex, and more transient risks including
the time of day, and emotional stress, for example.[2,3]
The underlying mechanism proposed by the authors to explain their
findings is that of ‘an increase in sympathetic tone’ in cold weather. It
is unfortunate then that the authors made no attempt to correlate their
findings with local meteorological data.
Months of the year are conveniently grouped into 2 ‘seasons’ -
‘winter’ and ‘summer’. Thus their peak occurrence of haemopericardium in
March falls within their ‘winter’ category. An analysis of data based on a
more conventional division of the year into 4 seasons may have been more
meaningful.
Despite commenting on the possibility that the study population may
not be representative of other areas ‘within London’, there is no analysis
of ethnicity. An opportunity has therefore been missed to examine the
relationship between ethnicity, fatal myocardial infarction and the
development of haemopericardium.
Other factors that would have been of interest in a Coronial
population from an area such as East London (and in particular the London
Borough of Tower Hamlets) include indicators of deprivation, which could
provide additional information about the underlying risks for fatal
cardiac events.
The development of a haemopericardium as a complication of myocardial
infarction reflects the complex interplay between various risk factors,
and as such demands a rigorous multivariate analysis for potentially
confounding factors. A follow up study by the authors addressing these
issues will be eagerly awaited.
References
1. Biedrzycki O, Baithun S. Seasonal variation in mortality from
myocardial infarction and haemopericardium. A postmortem study. J Clin
Pathol. 2006; 59:64-66.
3. Willich SN, Maclure M, Mittleman M et al. Sudden cardiac death –
support for a role of triggering in causation. Circulation. 1993; 87(5):
1442-1450.
The authors of this paper observe that, "The severity of hypoxia
determines whether cells become apoptotic or adapt to hypoxia and survive.
A hypoxic environment devoid of nutrients prevents the cell undergoing
energy dependent apoptosis and cells become necrotic....During hypoxia, an
intricate balance exists between factors that induce or counteract
apoptosis, or even stimulate proliferation".[1]
The authors of this paper observe that, "The severity of hypoxia
determines whether cells become apoptotic or adapt to hypoxia and survive.
A hypoxic environment devoid of nutrients prevents the cell undergoing
energy dependent apoptosis and cells become necrotic....During hypoxia, an
intricate balance exists between factors that induce or counteract
apoptosis, or even stimulate proliferation".[1]
In myocytes the likelihood of devloping apoptosis appears to be
dependent upon interstitial pH increasing as the pH falls to abnormally
low levels[2] as it does when an energy deficit develops in cells.
In an earlier communication to Heart[3] it was asked, "Might it be
that apoptosis, an ATP-dependent process, is an altruistic sacrifice
intended to protect adjacent cells from the harmful effects of the
inflammatory response induced by free radical release and cellular
necrosis should it occur? [The absence of an inflammatory response in
apoptosis is a striking feature distinguishing it from necrosis]. Might
apoptosis even be a physiological stimulus for myocyte renewal?"
A corollary of this myocyte buddy hypothesis is that apoptotic cells
might protect contiguous cells under reductive/oxidative stress by
providing them with a supplementary supply of nutrients in times of stress
independently of an overextended blood supply. Necrosis might only occur,
and an inflammatory response be initiated, when this hypothetical
supplementary supply of nutrient fails to meet the metabolic needs of
stressed cells. [Anaerobic glycolysis is the dominant means of ATP
resynthesis in healing wounds and malignant tumours but hardly ever to the
total exclusion of oxygen. This implies that the dependence upon nutrient
relative to oxygen delivery is abnormally increased in these
circumstances].
What then determines the ultimate fate of cells? The studies cited
above suggest that apoptosis and/or necrosis might only occur when the
interstitial pH has fallen below 6.86 or even 6.80. In which case cells
exposed to an abnormally low pH higher than that, possibly one between
7.32 and 6.90, might be subjected to increasing cellular disorder the
effects of which could be an added risk of genetic damage and/or mutation.
This could be an evolutionary advantage in unicellular organisms and one
that might even be the product of quantum tunnelling.[4]
Cellular proliferation is induced under similar metabolic
circumstances in an healing wound but must be accompanied by an abnormal
elevation in pH because of the reductuive biosynthesis in progress.
Angiogenesis, which also appear to be induced by the hypoxia inducible
factor 1 [5], is presumably a prerequisite for the delivery of adequate
nutrient to sustain the anaerobic glycolysis needed in an healing wound
and indeed tumour growth. This requires an abnormally good supply of blood
for much more nutrient must be delivered to generate 1 mol ATP by
anaerobic glycolysis than by oxidative phosporylation. A return to a
nornal tissue pH (7.40) can be expected to occur in an healed wound but
might not occur in a growing tumour. Rapidly growing tumoursmight,
however, be especially susceptible to a precipitous decline in pH induced
by an nadequate supply of nutrient and hence to the cellular necrosis
commonly seen in the center of a rapidly growing tumour.
The "intricate balance [that] exists between factors that induce or
counteract apoptosis, or even stimulate proliferation"[1] and possibly
even invasion and metastatic spread might be defined and even determined
by the ambient pH. This appears not only to be an index of but might even
be a determinant of[6] the metabolic environment present. The activity of
HIF-1 may even be determined by the ambnient pH which falls precipitously
in stagnant hypoxia unless preceded by cardiac arrest.[7]
References
1. A E Greijer and E van der Wall
The role of hypoxia inducible factor 1 (HIF-1) in hypoxia induced
Apoptosis. J Clin Pathol 2004; 57: 1009-1014.
2. Thatte HS, Rhee JH, Zagarins SE, Treanor PR, Birjiniuk V,
Crittenden MD, Khuri SF. Acidosis-induced apoptosis in human and porcine
heart. Ann Thorac Surg. 2004 Apr;77(4):1376-83.
3. Richard G Fiddian-Green. A myocyte buddy system in stressed myocardium?
http://www.heartjnl.com/cgi/eletters/90/4/425#393, 2 Aug 2004
4. Jim Al Khalili. Quantum: A Guide for the Perplexed.
6. Cain SM. pH effects on lactate and excess lactate in relation to
O2 deficit in hypoxic dogs. J Appl Physiol. 1977 Jan;42(1):44-9.
7. Grum CM, Fiddian-Green RG, Pittenger GL, Grant BJ, Rothman ED,
Dantzker DR. Adequacy of tissue oxygenation in intact dog intestine.
J Appl Physiol. 1984 Apr;56(4):1065-9.
The article by WS Smellie and colleagues[1] recommends not requesting
total IgE levels when requesting allergen specific IgE. We agree that
total IgE on its own neither rules in nor rules out the diagnosis of
allergy. However, total IgE levels are useful in the interpretation of
specific IgE tests, because they permit the ascertainment of possible
false-negative or false-positive results. Although thi...
The article by WS Smellie and colleagues[1] recommends not requesting
total IgE levels when requesting allergen specific IgE. We agree that
total IgE on its own neither rules in nor rules out the diagnosis of
allergy. However, total IgE levels are useful in the interpretation of
specific IgE tests, because they permit the ascertainment of possible
false-negative or false-positive results. Although this may not be as
important in the interpretation of aeroallergen-specific IgE results, this
consideration is vital in determining possible causes of anaphylaxis.
High total IgE may cause false positive specific IgE tests. High IgE
level are more common in males, smokers and severe eczema [2]. Mehl A and
colleagues[3] found that the ratio of food-specific / total IgE had a
significant correlation with outcome from food challenge (cow’s milk,
hen’s egg, wheat and soy) but specific IgE estimations were just as
reliable. M Kerkhof and colleagues demonstrated that the elevated total
IgE ‘outpaces’ specific IgE in younger individuals (aged 20-44 years),
suggesting that in this cohort, negative specific IgE should guide the
clinician towards looking for IgE against other allergens [4].
Low IgE (<10 IU/ml) are rarely associated with findings of
positive specific IgE results, although positive IgE at these low total
IgE levels may be extremely significant [5]. Knowing that the total IgE is
low becomes essential when interpreting negative specific IgE tests in the
context of anaphylaxis for example.
Yours faithfully,
S Khan*
S Holding**
PC Doré**
WAC Sewell*
*Path Links Immunology, Scunthorpe General Hospital, Scunthorpe, DN15
7BH, UK.
**Department of Immunology, Hull Royal Infirmary, Hull, HU3 2JZ, UK.
Competing interests: None.
References
1.Smellie WS, Forth JO, McNulty CA, Hirschowitz L, Lilic D, Gosling R,
Bareford D, Logan E, Kerr KG, Spickett GP, Hoffman J, Galloway A, Bloxham
CA. Best practice in primary care pathology: review 2. J Clin Pathol. 2006
Feb; 59(2): 113-20.
2.Wuthrich B, Schindler C, Medici TC, Zellweger JP, Leuenberger P. IgE
levels, atopy markers and hay fever in relation to age, sex and smoking
status in a normal adult Swiss population. SAPALDIA (Swiss Study on Air
Pollution and Lung Diseases in Adults) Team. Int Arch Allergy Immunol.
1996 Dec; 111(4):396-402.
3.Mehl A, Verstege A, Staden U, Kulig M, Nocon M, Beyer K, Niggemann B.
Utility of the ratio of food-specific IgE/total IgE in predicting
symptomatic food allergy in children. Allergy. 2005 Aug; 60(8): 1034-9.
4.Kerkhof, M., Dubois, A. E. J., Postma, D. S., Schouten, J. P. &
Monchy, J. G. R. Role and interpretation of total serum IgE measurements
in the diagnosis of allergic airway disease in adults. Allergy 2003; 58
(9): 905-911.
5.Sinclair D, Peters SA The predictive value of total serum IgE for a
positive allergen specific IgE result.J Clin Pathol. 2004 ; 57(9): 956-9.
It was interesting to read the audit of thrombophilia screens [1]. It
was however stated that "Only 11 of the 47 laboratories surveyed routinely
carried out a total protein S assay" and "The BCSH guidelines suggest that
only the total protein S assay should be used as a screening test, and if
this is abnormal, then a free protein S assay should be performed”. In
fact the guideline [2] does not recommend...
It was interesting to read the audit of thrombophilia screens [1]. It
was however stated that "Only 11 of the 47 laboratories surveyed routinely
carried out a total protein S assay" and "The BCSH guidelines suggest that
only the total protein S assay should be used as a screening test, and if
this is abnormal, then a free protein S assay should be performed”. In
fact the guideline [2] does not recommend this and many laboratories
measure free protein S directly which is fully in accordance with the
guideline. However, for other reasons, we think the time has come to re-
write the guideline and the Haemostasis and Thrombosis Task Force of the
BCSH will be doing so this year.
References
1. Lyons, S., et al., An audit of thrombophilia screens: results from
the National Pathology Alliance benchmarking review. J Clin Pathol, 2006.
59(2): p. 156-9.
2. Walker, I.D., M. Greaves, and F.E. Preston, Investigation and
management of heritable thrombophilia. Br J Haematol, 2001. 114(3): p. 512-28.
Our best practice guidelines for the diagnosis of allergy advise that
routine requesting of total IgE measurements is not necessary; instead we
advise requesting allergen-specific IgE based on clinical findings. Khan
et al. argue that measurement of total IgE levels permits ascertainment of
possible false-negative or false-positive specific IgE results. However,
the examples given provide only a circum...
Our best practice guidelines for the diagnosis of allergy advise that
routine requesting of total IgE measurements is not necessary; instead we
advise requesting allergen-specific IgE based on clinical findings. Khan
et al. argue that measurement of total IgE levels permits ascertainment of
possible false-negative or false-positive specific IgE results. However,
the examples given provide only a circumstantial indication of the
possibility of false positive or negatives in rare cases. In the context
of primary care testing, the issue in question is whether total IgE should
be requested systematically alongside all specific IgE requests, or only a
posteriori in specific cases. Current evidence suggests that in the vast
majority of cases, assessment of total IgE increases costs unnecessarily
as it does not add to the diagnosis and management of allergy patients. In
the example given of anaphylaxis, we would recommend such cases to be
investigated in conjunction with a consultant immunologist.
The authors confirm that increased levels of total IgE may be found
in situations without an allergic background, are therefore not predictive
of allergic sensitisation and consequently have little positive predictive
value for the diagnosis of allergy. We agree with this statement. Further,
the authors acknowledge that low IgE does not rule out sensitisation,
which can only be assessed by testing for allergen-specific IgE; one of
the references quoted (Sinclaire d et al) – although advising that total
IgE should be performed as a screening test which would exclude specific
IgE if low – goes on to conclude that specific IgE testing should be
performed regardless of total IgE levels when there are convincing
clinical reasons to do so. We agree with this statement. The authors quote
findings in support of a correlation between total IgE and specific IgE
levels (Kerkhof m et al) in food allergy, although specific IgE alone was
found to be just as reliable. We again agree.
The authors however, correctly point out that very high levels of
total IgE can give false positive specific IgE results, which we did not
specifically address in our guidelines. We agree this can be relevant, but
feel that these situations are relatively rare and do not justify regular
requesting of total IgE; our advice would be to request total IgE a
posteriori if the results of specific IgE testing suggest that non-
specific binding is the reason for the false positive (i.e. multiple or
all allergens tested are positive).
Even though not mentioned in the letter, it is important to stress
that measuring total IgE may have previously been of significance in
calculating the amount (i.e. quantitation) of specific IgE present; this
is now bypassed by the inclusion of international reference standards for
total IgE in kits measuring specific IgE, enabling the expression of
specific IgE quantitatively in international units rather than semi-
quantitatively in scores.
Finally it is of note that the American Academy of Allergy, Asthma
and Immunology (AAAAI) and American College of Allergy, Asthma and
Immunology (ACAAI) recently published guidelines on food allergy (Annals
Asthma Allergy Immunol, 2006, 96(3) supp:1-68) in which they neither
mention nor recommend measurement of total IgE in patients with food
allergy.
We are grateful for the comments by Khan et al. These guidelines are
intended for regular review and wide professional input wherever possible.
Dear Sirs,
We have read with interest and concern the correspondence letter published in the July issue of your journal “OSNA testing for lymph node staging in colorectal cancer”.
Show MoreAlthough the authors state on the letter “We aim to provide unbiased data on the diagnostic accuracy of OSNA in detecting CRC nodal metastases and feedback the practicalities of running such a service in a National Health Service (NHS) cellular pathology department”, we think the information given in their article is somehow incomplete. Their conclusions are based on the analysis of 99 lymph nodes (LNs) from a small cohort of 19 cases, with only 5.2 LNs examined per patient. Current guidelines, including the guidance of The Royal College of Pathologists, recommend that at least 12 LNs should be assessed to ensure an adequate specimen evaluation and a reliable pathologic staging.[1] In contrast, several studies using colon cancer OSNA lymph node analysis have assessed 12 or more LNs.[2–4]
We agree with their statement that intraoperative OSNA detection of LN metastasis does not have a role in CRC surgery, mainly because regional lymphadenectomy is invariably included with the colectomy specimen. But this is not the target of molecular lymph node assessment in CRC. The most important clinical application of molecular LN analysis in CRC is that it enables a more precise staging in early CRC than the one obtained with conventional H&E analysis, especially useful for stage II pa...
Good Morning,
I just want to put out a typo in figure (1) : the sokal score formula should be : exp(0.0116*(age - 43.4 ) + ... and not exp(0.0116*(age - 4.34 ) +... .
If you use 4.34 all you patients will be in "High Risk Group".
source : Sokal JE, Cox EB, Baccarani M, Tura S, Gomez GA, Robertson JE, et al. Prognostic discrimination in « good-risk » chronic granulocytic leukemia. Blood. 1 avr 1984;63(4):789‑99.
http://www.bloodjournal.org/content/63/4/789.long?sso-checked=true
Sincerely
Jim Canet
Dear Editor
In a previous issue of this journal, we presented problems of using Bouin’s fixative for immunohistochemical and nuclear morphometric assays on prostatic biopsies(1). We agree with the important comment offered by Berney that Bouin’s fixative could increase the sensitivity for detection of high grade prostatic intraepithelial neoplasia (HGPIN) and prostate cancer. Furthermore, we agree that increa...
Dear Editor,
I gather from the article that an overseas graduate with an experience in Pathology can directly apply for SpR post, but the rcpath website says it is not so for histopathology. I would like to know if an overseas graduate with an experience in Pathology equivalent to the award of CCST can directly get into SpR post?
Dr Tandon: You should contact the RCPath directly and get a ruling pertinent to your qualifications and experience.
Professor Runjan Chetty
Editor, The Journal of Clinical Pathology
Dear Editor,
I read with interest the recent article by Biedrzycki and Baithun[1] investigating the relationship between myocardial infarction complicated by haemopericardium, and season. The study utilised data collected during Coronial postmortem examinations, carried out over a 5-year period in East London. They concluded that there was indeed a ‘seasonal variation’ for this entity, and that the likelihood of ven...
Dear Editor,
The authors of this paper observe that, "The severity of hypoxia determines whether cells become apoptotic or adapt to hypoxia and survive. A hypoxic environment devoid of nutrients prevents the cell undergoing energy dependent apoptosis and cells become necrotic....During hypoxia, an intricate balance exists between factors that induce or counteract apoptosis, or even stimulate proliferation".[1]
...Dear Editor,
The article by WS Smellie and colleagues[1] recommends not requesting total IgE levels when requesting allergen specific IgE. We agree that total IgE on its own neither rules in nor rules out the diagnosis of allergy. However, total IgE levels are useful in the interpretation of specific IgE tests, because they permit the ascertainment of possible false-negative or false-positive results. Although thi...
Dear Editor,
It was interesting to read the audit of thrombophilia screens [1]. It was however stated that "Only 11 of the 47 laboratories surveyed routinely carried out a total protein S assay" and "The BCSH guidelines suggest that only the total protein S assay should be used as a screening test, and if this is abnormal, then a free protein S assay should be performed”. In fact the guideline [2] does not recommend...
Dear Editor,
Our best practice guidelines for the diagnosis of allergy advise that routine requesting of total IgE measurements is not necessary; instead we advise requesting allergen-specific IgE based on clinical findings. Khan et al. argue that measurement of total IgE levels permits ascertainment of possible false-negative or false-positive specific IgE results. However, the examples given provide only a circum...
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